M. G. Katz1, W. Y. Rockne2, R. Braga1, S. McKellar1, A. Cochran1,3 1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University Of Utah,School Of Medicine,Salt Lake City, UT, USA 3Ohio State University,Department Of Surgery,Columbus, OH, USA
Introduction:
Healthcare provider behavior, communication, and performance can all lead to mistakes that harm patients. Primary mechanisms of identifying patient safety issues include open communication and non-punitive reporting of near misses and adverse events; therefore patient safety event reporting systems have become a mainstay in identifying safety events and quality problems. We hypothesized that an upgraded reporting system that included the ability to report positive behaviors would increase reporting of behavioral events in the perioperative environment.
Methods:
At a tertiary university hospital we performed a retrospective assessment of prospectively collected reports from the Patient Safety Net (PSN) event reporting system (2/2010 – 2/2015) and the RL Solutions RL6 system (8/2015-4/2018).
Results:
Under the PSN system, 13 behavioral events were submitted, averaging 0.8/quarter, compared to the RL6 system, where 81 events were submitted, averaging 7.4/quarter. The average length of reports increased from 61 to 185 words per report. Events were most often reported by nursing staff (66%), while attending physicians were the group most commonly identified as displaying disruptive behavior (36%). The majority of events under both systems (100% and 54% respectively) resulted in no harm according to reporters. 22% of reports under the RL6 system were positive reports; 46% of these positive reports were about physicians.
Conclusion:
After implementation of an upgraded reporting system that includes an option for positive reporting, the number and length of reports have increased. We believe that a robust reporting system that includes options for positive reporting has contributed to improved feedback on the culture of safety at our institution.
