Identification by families of pediatric adverse events and near misses overlooked by health care providers.

BACKGROUND: Identifying adverse events and near misses is essential to improving safety in the health care system. Patients are capable of reliably identifying and reporting adverse events. The effect of a patient safety reporting system used by families of pediatric inpatients on reporting of adverse events by health care providers has not previously been investigated. METHODS: Between Nov. 1, 2008, and Nov. 30, 2009, families of children discharged from a single ward of British Columbia's Children's Hospital were asked to respond to a questionnaire about adverse events and near misses during the hospital stay. Rates of reporting by health care providers for this period were compared with rates for the previous year. Family reports for specific incidents were matched with reports by health care providers to determine overlap. RESULTS: A total of 544 familes responded to the questionnaire. The estimated absolute increase in reports by health care providers per 100 admissions was 0.5% (95% confidence interval -1.8% to 2.7%). A total of 321 events were identified in 201 of the 544 family reports. Of these, 153 (48%) were determined to represent legitimate patient safety concerns. Only 8 (2.5%) of the adverse events reported by families were also reported by health care providers. INTERPRETATION: The introduction of a family-based system for reporting adverse events involving pediatric inpatients, administered at the time of discharge, did not change rates of reporting of adverse events and near misses by health care providers. Most reports submitted by families were not duplicated in the reporting system for health care providers, which suggests that families and staff members view safety-related events differently. However, almost half of the family reports represented legitimate patient safety concerns. Families appeared capable of providing valuable information for improving the safety of pediatric inpatients.

Barriers to and incentives for safety event reporting in emergency departments.

Patient safety events (PSEs) are common in healthcare and may be particularly prevalent in complex care settings such as emergency departments (EDs). Systems for reporting, analyzing, learning from and responding to incidents are promoted as a means to reduce adverse events by facilitating feedback, learning and system change. However, only 4-50% of PSEs are reported. Under-reporting masks the true number of PSEs and may reduce our ability to learn from and prevent repeat events. The goal of this study was to identify barriers that prevent PSE reporting and incentives that encourage reporting. Semi-structured interviews were carried out with front-line nursing staff and nurse managers in EDs across British Columbia to explore their perception of barriers to and incentives for PSE reporting. Interviews were recorded, transcribed, checked for accuracy and entered into NVivo 8 software. Data were analyzed thematically as they were acquired, and emerging themes were explored in subsequent interviews. One hundred six interviews were conducted with staff from 94 of the 98 EDs in British Columbia. Six main barriers to PSE reporting were identified: (1) time constraints, (2) a sense of futility, (3) fear of reprisal, (4) a lack of education on PSE reporting, (5) reports being viewed as indicators of incompetence and (6) an inaccessibility of reporting forms. Incentives for reporting included valuing PSE reporting, the availability of alternative reporting pathways and feedback and visible changes resulting from PSE reports. We identified barriers that restrain nurses from reporting PSEs and incentives that facilitate reporting. Our findings should be considered when developing systems to report and learn from PSEs.

Establishing a provincial patient safety and learning system: pilot project results and lessons learned.

An effective safety event reporting system is an essential part of a comprehensive patient safety program. In British Columbia, we are implementing a provincial web-based event reporting tool and learning system called the BC Patient Safety and Learning System (PSLS). In this paper, we describe and report the results of our pilot study in a neonatal intensive care unit at BC Women's Hospital in Vancouver. Our approach aimed to foster a culture of safety by using the technology implementation to facilitate organizational learning about patient safety and to promote sustainable reporting behaviours. Results showed that PSLS was enthusiastically adopted by staff and enabled efficient reporting, promoted timely and complete follow-up activities and facilitated quality improvement. Our lessons learned laid the foundation for the provincial rollout of PSLS and may be of interest to those implementing similar systems elsewhere.

Laboratory error reporting rates can change significantly with year-over-year examination.

BACKGROUND: Incident reporting systems are useful tools to raise awareness of patient safety issues associated with healthcare error, including errors associated with the medical laboratory. METHODS: Previously, we presented the analysis of data compiled by the British Columbia Patient Safety & Learning System over a 3-year period. A second comparable set was collected and analyzed to determine if reported error rates would tend to remain stable or change. RESULTS: Compared to the original set, the second set presented changes that were both materially and statistically significant. Overall, the total number of reports increased by 297% with substantial changes between the pre-examination, examination and post-examination phases (χ2: 993.925, DF=20; p<0.00001). While the rate of change for pre-examination (clerical and collection) errors were not significantly different than the total year results, the rate of change for reporting examination errors rose by 998%. While the exact reason for dramatic change is not clear, possible explanations are provided. CONCLUSIONS: Longitudinal error rate tracking is a useful approach to monitor for laboratory quality improvement.

Medical laboratory associated errors: the 33-month experience of an on-line volunteer Canadian province wide error reporting system.

BACKGROUND: This article reports on the findings of 12,278 laboratory related safety events that were reported through the British Columbia Patient Safety & Learning System Incident Reporting System. METHODS: The reports were collected from 75 hospital-based laboratories over a 33-month period and represent approximately 4.9% of all incidents reported. RESULTS: Consistent with previous studies 76% of reported incidents occurred during the pre-analytic phase of the laboratory cycle, with twice as many associated with collection problems as with clerical problems. Eighteen percent of incidents occurred during the post-analytic reporting phase. The remaining 6% of reported incidents occurred during the actual analytic phase. Examination of the results suggests substantial under-reporting in both the post-analytic and analytic phases. Of the reported events, 95.9% were reported as being associated with little or no harm, but 0.44% (55 events) were reported as having severe consequences. CONCLUSIONS: It is concluded that jurisdictional reporting systems can provide valuable information, but more work needs to be done to encourage more complete reporting of events.

Creating a safety culture at the Children's and Women's Health Centre of British Columbia.

The Children's' and Women's Health Centre of British Columbia (C&W) is the largest hospital providing specialized care to women and children across the province of British Columbia in Canada. The values of quality and safety are threaded throughout the C&W strategic plan which emphasizes that safety is vital for better health. At C&W, a multifaceted approach is used to create and sustain a culture of safety. The Institute for Healthcare Improvement (IHI) has developed tools to facilitate the development of safety cultures within hospital settings. This article describes the implementation of some of these tools, such as the Safety Briefings Model and Patient Safety Leadership Walkrounds. We will discuss how we adapted these strategies to our pediatric settings; what we learned through the implementation process-our successes and challenges; and implications for future success.