You can’t improve without knowing what’s wrong

In the healthcare quality improvement field, there has been much talk about reporting errors, about a just culture, about using occurrence reporting data to implement quality improvement initiatives, and sharing results with staff. But it seems, according the latest Office of the Inspector General (OIG) report that many of you have probably seen, that hospitals aren’t cutting it.

In summary, the report concludes:

 Hospital incident reporting systems captured only an estimated 14 percent of the patient harm events experienced by Medicare beneficiaries. Hospital administrators classified the remaining events (86 percent) as either events that staff did not perceive as reportable (61 percent) or as events that staff commonly report but did not report in this case (25 percent).

So, the majority of events go unreported because staff didn’t think the event qualified for the reporting system.

A list of common events is coming (via AHRQ and CMS), and it’s sure to be helpful. Until then, hospitals should work on  what Occurrence Reporting: Building a Robust Problem Identification and Resolution Process author Ken Rohde calls this a reporting threshold.

“If your staff question whether they should report something, they are asking themselves a threshold question,” says Rohde. He advises the threshold to be either low or nonexistent.

“A good way to communicate a lower threshold is to tell staff: ‘If it was important enough for you to think about it or if it disrupted your day, then report it,’” says Rohde.

Though a higher reporting volume may require a more efficient screening process, more information about adverse events is usually better.

Here’s a quick tip sheet from Rohde’s best-selling book for improving your error reporting in your system:  http://patientsafetymonitor.com/tools-library (starred, at the bottom, free for download).