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

2. 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

3. 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.

4. 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

5. 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

6. 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

7. impact of Patient Safety events:

8. 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

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

10. “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

11. “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

12. 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

13. 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!!!

14. Additional information about patient safety event reporting (FAQs, education, contacts, etc.) can be found on the Patient Safety site on Pulse