Voluntary Reporting: A Foundation for an Informed Culture of Safety in Critical Access Hospitals Mar

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Voluntary Reporting A Foundation for an Informed
Culture of Safety in Critical Access
HospitalsMarch 16, 2007

• Katherine Jones, PhD, PT
• Supported by AHRQ Grant
• 1 U18 HS015822

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Background Implementing a Program of Patient
Safety in Small Rural Hospitals

• One of 17 AHRQ PIPs grants funded July 2005
• Purpose to implement the patient safety
  practices of voluntary medication error reporting
  and organizational learning in small rural
  hospitals
• AIM 1 Develop the organizational infrastructure
  for reporting, providing timely feedback, and
  analyzing medication errors

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Small Rural Hospitals (2005)

• 4,936 community hospitals in US31 (1,523) have
  lt 50 beds
• 70 (1,059) of these 1,523 small rural hospitals
  are Critical Access Hospitals (CAHs)
• Licensed for up to 25 beds
• Average length of stay of 96 hours
• 1/3 have a pharmacist onsite lt 10 hours/week
• 1/3 contract with a local community pharmacist
• 52 directly employ a pharmacist
• CAHs in our project in 2005 24 in NE, 1 in WY

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Questions

• How is reporting affected by limited availability
  of pharmacists?
• How can you build a commitment to reporting in
  organizations with limited human, technical, and
  financial resources?
• What methods of event reporting have participants
  developed and found useful?
• How does a third party enhance data collection,
  data quality, and data analysis?

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Reporting Differences by Severity
ALL HOSPITALS
25 CAHs
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Reporting Differences by Phase
ALL HOSPITALS
25 CAHs
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• Reporting
• Differences by Type

ALL HOSPITALS
25 CAHs
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Limited Resources A Team of 1

• RN with limited computer skills
• Limited pharmacy support
• Limited support from senior leadership
• Limited knowledge of patient safety principles
• Wearing multiple hats
• Ignorant board wants zero errors

DON, Risk Manager, QI, inf control, data entry
who am I today?
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Building Commitment A Strategy for Leading
Change

• Engageinitial site visit, process map
• Educateaudioconferences, workshops, facilitation
  for root cause analyses
• Executeimplement system change based on
  medication error reports and comparison of
  process to evidence based best practice
• EvaluateAHRQ Hospital Survey on Patient Safety
  Culture

Pronovost et al. (2006). Creating High
Reliability in Health Care Organizations. Health
Services Research, 41, 1599 1617,
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Sample Map of Medication Use
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Development of the Near Miss Short Form
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Enhancement of Data Quality with Feedback on
Accuracy
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Enhancement of Data Analysis with Quarterly
Report Templates
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Enhancement of Data Analysis Aggregate RCA
Aggregate Analysis of 58 Category C Wrong Time
Errors... Lack of teamwork to handle fluctuating
workload accounts for (45) 78 of wrong time
errors pt. in ED accounts for (19) 42 of
workflow disruption
Ordering
Transcribing/ Documenting
Dispensing
Workflow disruption (78 of Causes) Pt. in ED,
Code, patient admitted/ discharged
Administering
Monitoring
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Reporting is the Foundation
Reason, J. (1997). Managing the Risks of
Organizational Accidents. Hampshire, England
Ashgate Publishing Limited.
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Katherine Jones, PhD, PT kjonesj_at_unmc.edu