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Quality Update - From Event Reports to Actions

Fall 2009

From Event Reports to Actions

Date: October 15, 2009

Patient Safety Director Lori Paine describes how The Johns Hopkins Hospital leverages adverse event reports to improve care.

lori paine

After The Johns Hopkins Hospital replaced its paper-based adverse event-reports with the online Patient Safety Net system, leaders realized that they needed a strategy for turning those reports into improvements. Lori Paine, director of patient safety for the hospital and the Center for Innovation, explains Hopkins’ system for sorting through more than 200 entries per week, ensuring follow-up and making system fixes.

Who reads a report after it’s submitted?
Usually more than one person reads each report. In 2005, we hired a patient safety analyst to review every event, make sure that it’s sent to all relevant people, and seek clarifications from the person filing the report if information isn’t clear.

Reports also go automatically to people in the organization who are “mapped” by the Patient Safety Net system to receive them. A report about an event involving anticoagulation therapy, for instance, would go to the nurse manager on the unit where it occurred, to assigned pharmacy leaders, to departmental quality improvement staff, and to an anticoagulant task force that reviews all such events throughout the hospital.

Aside from these automatic notifications, how does the hospital sort through reports?
We have a group called HEAT—the Hopkins event action team—that meets weekly to review reports, discuss trends and make sure that someone takes charge of the investigation. The team is led by our vice president of medical affairs and includes high-level faculty, risk management, pharmacy and nursing. Before each meeting, the patient safety analyst reviews the week’s reports and culls out the ones that are most concerning, either because of potential harm or harm that actually happened.

Does this team investigate all of these events on its own?
No. One of HEAT’s main functions is making sure that the appropriate people are looking into incidents. One way we do this is by categorizing events under more than a dozen safety indicators—mislabeled specimens, for instance—and forwarding them to groups that have been assigned to review them. HEAT also makes sure that other types of adverse events without “homes”—people or groups already responsible for reviewing them—are addressed. For instance, we’ve tracked events involving violations of the code of conduct.

What’s an example of a safety issue that the group has helped to address?
When we were looking at handoff-related events, we realized that there were a fair number that had to do with transitions of care during the transport process. So we decided to have a group look at transport completely separately. Now a patient transport events team has made a variety of changes based on the reports, such as requiring that glucose meters be available on all transports. In the past there were reports of patients who would get transported off their unit for lengthy periods without necessary monitoring.

What advice do you have for hospitals looking to improve their follow-up of event reports?
Don’t be fooled into thinking that the high-harm events are always the most significant. Recently, our patient safety analyst flagged an event report from an ICU nurse who noted an unsafe condition: A bag of the paralytic vecuronium, a high-risk medication, was being stored in a medication refrigerator next to similar looking bags of antibiotics. Recognizing the potential for a nurse to accidentally grab and administer the vecuronium, we brought this to the attention of a group that reviews significant medication events. The group immediately put strategies in place for packaging and labeling vecuronium bags so the contents are more obvious.

Rather than waiting for bad things to happen, we need to do a better job of addressing these unsafe conditions and near misses so they don’t occur in the first place.