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The purpose of this project was to evaluate methods that might increase hazard reporting, especially reports where harm did not occur. The two methods evaluated were ease of entry and regular feedback to the staff on what was being entered and what was being done about the entries.
Significance:
Reporting near misses is important in any proactive safety initiative. Identifying potential safety hazards can allow for solutions and processes to be put in place before harm occurs. Estimates show 600 near misses for each actual occurrence.
Strategy and Implementation:
Six of our adult ICUs have been participating in the Comprehensive Unit-Based Safety Program (CUSP) since 2010. One of the tenets of CUSP is to identify and evaluate defects. There was an occurrence reporting system (ORS) in place, but staff tended to report more actual events than near misses, and even then, did not report all events. We conducted a five month trial of a third party hazard reporting system with a simple interface for collecting narrative on actual and potential hazards. The reports could be anonymous and took an average of 2 minutes to complete. Immediate messages could be sent to unit leadership for acute events. A weekly feedback system to notify the staff of trends noted and leadership response to identified hazards was put in place. Rates and topics were compared between the trial system and the legacy system. Data from the legacy system was evaluated for the three months just prior to the trial and three months in the previous year.
Evaluation:
There were 1048 entries in the trial system during the 5 months (average 210/month). In the nine months of comparative entries from the legacy system, there were 370 (41/month). There were some distinct differences in topics, especially regarding team communication.
Implications for Practice:
Unit staff will enter more near misses and actual events if the reporting system is simple to use and anonymous and if the staff gets regular feedback that their reporting is taken seriously and being acted upon by the management team.