E. C. Hamilton1,2, D. H. Pham1, A. N. Minzenmayer1, L. S. Kao3, K. P. Lally1,2, K. Tsao1,2, A. L. Kawaguchi1,2 1University Of Texas Health Science Center At Houston,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 3University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA
Introduction:
Electronic hospital variance reporting systems are plagued by underreporting. Variances include near misses (unplanned events that fail to cause patient harm, but had the potential to do so) and adverse events (unplanned events cause actual patient harm). To capture as many variances as possible, we have both electronic and handwritten variance reporting systems in place. The purpose of this study is to prospectively evaluate variances that occur in our pediatric operating room and to compare these variances to the two established incident reporting systems in our hospital.
Methods:
In this prospective observational study, trained individuals directly observed pediatric perioperative patient care for six weeks to identify near misses and adverse events in domains including timeout, medication, equipment, blood bank, surgical counts, and isolation. These direct safety observations were compared to the handwritten perioperative variance reporting system and the electronic hospital variance reporting system. All observations were analyzed and categorized into an additional six safety domains (adverse event, near miss, safety process issue, non-safety issue, indeterminate, good job) and five variance categories (equipment/supplies, knowledge/attitude, policies/process, environment, operations, other). The chi-square test was used, and p-values <0.05 were considered statistically significant.
Results:
Out of 211 observed cases, 137 near misses were identified by trained observers, while 57 handwritten variance reports and 8 electronic reports were filed during the same time period. Only 2 of 137 observed events were also reported in the handwritten or electronic system. Five observed adverse events were not reported in either of the two incident reporting systems. Safety observers were more likely to recognize timeout and equipment variances (graph). Both handwritten variance cards and safety observers identified numerous policy and process issues. The electronic variance system was used infrequently and most often to report intentional incorrect counts. All systems addressed knowledge/attitude and policy/process issues most often and there were no differences for frequency of safety categories (P=0.19).
Conclusion:
Despite multiple reporting systems, near misses and adverse events are vastly underreported. By identifying and addressing near misses, the underlying causes of system and processes can be corrected before they lead to an adverse event. Efforts need to be made to lessen barriers to variance reporting in order to improve patient safety.
