Rewarding near-miss reporting

By now, most of us involved in patient safety understand the importance of reporting, collecting, and analyzing near misses. More and more, healthcare providers are beginning to understand that more often than not, a systematic problem—not an individual—is behind potentially dangerous errors.

But how do you get staff to report them? No really—actually report them? Including physicians? Many healthcare providers have been working in the field for decades, and for many of those decades, mistakes were swept under the rug—especially mistakes that luckily did not reach the patient. No harm, no foul, no reporting–this was a common way of thinking for many years. When providers have learned and worked in an environment where reporting errors often meant severe individual punishment, how do get them to trust you that reporting is okay?

It’s critical to show staff the positive effects of near miss reporting. It’s also a good idea to publicly and consistently reward those who “see/experience something and say something.” A good example is one surgical suite in Johns Hopkins Hospital in Baltimore that implemented its Good Catch Awards. After 24 months, the health center provided a table of 27 good catches that shows how systems were changed in response to the catch, including one that led to a national recall of an improperly labeled drug that lead to look-alike medication errors.

Clinicians honored with an award receive public recognition with wall boards on the surgical suite. The system is not yet implemented hospital-wide, but continues at the Weinberg OR Suite at Johns Hopkins Hospital.

Do you have a near-miss reporting system? Is it used? Do staff receive public recognition for their efforts? Have you had trouble getting staff to trust that reporting is benefits all? Post your comments below.

Source: Anesthesiology News