Patient Safety Event Reporting: Why Bother? Pam Proctor MSN, RN Patient Safety Director, University of Utah Health Care

What is a patient safety event? Anything that harms, or threatens to harm a patient What is patient safety event reporting? Entering information about a patient safety event into our event reporting system, to provide an opportunity to improve care processes and prevent recurrence

Let’s start with an example : 78 yo female admitted for excision of cancerous masses, experienced a decline in status on post- op day three, and had delayed response to this deterioration. The scenario and concern over the associated delay in response was reported as a patient safety event.

Why bother to report…Here’s why: When a patient safety event occurs: WE ARE CHANGED – we now know patients can be unintentionally harmed while in our care THINK ABOUT THE “NEXT PATIENT” IN THE SAME SET OF CIRCUMSTANCES, that we want to protect from harm Our hope is to PREVENT THE SAME THING FROM HAPPENING AGAIN

Unreported events are missed opportunities to prevent future harm All events, near misses, or unsafe conditions (what is really happening) Missed opportunity to improve and prevent future harm REPORTED events, near misses, or unsafe conditions (what we know about) IMPROVEMENTS in follow-up to reported events We can’t fix problems we don’t know about

We can complain about things, OR “NEVER LET AN EVENT GO TO WASTE”… Use every event or risk as an opportunity to learn and improve Reporting is about serving both our patients and fellow team members, by honestly acknowledging problems, so they can be addressed

impact of Patient Safety events:

Let’s go back to our example: In response to the event report, an investigation was done to determine the root causes of the delay in response. Improvements in response to this event report included: Changes to General Surgery call coverage to better support residents Improvements to the resident sign-out process Improvements to some Epic orders related to acute patient changes Several changes to nursing care processes

is our patient safety event reporting system 1. Can be found: RL (Report & Learn) is our patient safety event reporting system

“Top 5” things you should know about patient safety event reporting 2. Everyone is encouraged to report safety events 3. Report any event – or hazard – that has, or could result in patient harm: Report the potential for harm - don’t need to wait for something bad to happen Adverse clinical events Inefficiencies/problems with care delivery “Top 5” things you should know about patient safety event reporting

“Top 5” things you should know about patient safety event reporting 4. It’s EASY to report! Log into RL with your uNID and password Select the icon that best fits the type of event being reported Complete the fields in the form to the best of your ability “Submit” “Top 5” things you should know about patient safety event reporting

rl6-3.rlsolutions.com/Utah_Prod_Mobile 5. There is an app (RL6) available for reporting events via a mobile device: Download RL6 mobile from your app store Select “manual entry” and configure device using this URL: rl6-3.rlsolutions.com/Utah_Prod_Mobile Click “connect”, login with uID and password, and fill in fields “Top 5” things you should know about patient safety event reporting

So…SPEAK UP!!! Reporting: IS NOT about finding fault or placing blame IT IS about identifying opportunities for how we can support you in “getting things right” So…SPEAK UP!!!

Additional information about patient safety event reporting (FAQs, education, contacts, etc.) can be found on the Patient Safety site on Pulse www.pulse.utah.edu/PatientSafety