Near-miss reports provide valuable information
Authority hopes data will prevent adverse events
Identification and reduction of potential adverse events and patient safety risks are required by all accreditation organizations, but not all outpatient managers look at using information from near misses to develop performance improvement projects to address risks. Pennsylvania programs not only are collecting data on near misses, but they also are required to include near miss information as well as adverse event information in reports to a state authority.
The Harrisburg-based Pennsylvania Safety Authority received 200,000 reports of adverse events last year, and 96% of the events were near-miss incidents in which something that could have injured a patient was stopped, caught, and fixed before the patient was harmed.
"It is important to capture information from near misses because causes of serious events are often the same causes identified in near miss reports," says Mike Doering, MBA, executive director of the authority. Examination of near-miss reports provides an opportunity to see what worked as well as what didn't work, Doering says. This proactive approach can help outpatient surgery programs identify and fix problems before harm is done, he adds.
Information on near miss incidents don't get reported to the Department of Health and don't affect a facility's licensure or accreditation status, Doering says. This information is used to identify trends or specific areas that need extra attention, he explains.
Difference with outpatient surgery errors
While hospital incidents most often are related to medication errors or falls, outpatient surgery incidents most often are related to errors or complications related only to the procedure, says Mary Blanco, RN, MSN, an analyst for the authority. "This difference makes sense because outpatient surgery patients are not in the facility long enough for a high risk of medication error or fall," she admits. "We are starting to see a trend in outpatients who seek medical care after discharge."
When a trend is identified, reporting facilities are asked what changes they made in their process and how the changes are working, says Blanco. After gathering this information and conducting literature searches for information related to the subject, an article is included in the quarterly publication, Patient Safety Advisories.
"Our Advisories are available on our web site for free," says Doering. "In fact, you can subscribe at no cost by signing up on the web site." This is a service that is available to all health care facilities, not just Pennsylvania-based organizations, he explains.
The trend in which outpatient surgery patients are seeking care following discharge raises a number of questions including how well did they understand discharge instructions, did they understand how much pain or bleeding to expect, and do they know who to call if they need help, Blanco says. Identification of this trend will help outpatient programs review their discharge procedures and their patient education to address these questions, she adds.
Articles in Patient Safety Advisories also may be generated by a request from a facility, says Bill Marella, project manager for the authority. "We were asked if all outpatient surgery programs required a responsible person to accompany the patient home and what constitutes a responsible person," Marella says. "The facility wanted to know if they were fulfilling their responsibility by putting the person in a cab."
Insisting that a responsible person accompany the patient as he or she is discharged is about more than just transportation, he points out. "The patient should have someone that can listen to discharge instructions, get the patient home safely, and ensure that the patient follows discharge instructions," he says. "However, there is no clear definition of responsible person." (Editor's note: The September 2007 issue of Patient Safety Advisory includes an article on this issue.)
More thorough screening process
Other hot topics for the Pennsylvania Safety Authority include wrong-site surgery and prescreening of patients, says Blanco. "Outpatient surgery programs are seeing an increasing number of complex cases, and we are seeing an increase in low oxygen levels or abnormal heart rhythms in patients," she says. When these reports come through, they ask if that patient was appropriate for outpatient surgery at all, Blanco says. "I think that outpatient surgery programs are seeing that their screening process needs to be more thorough and that they need to be ready to send the patient to the hospital for the procedure," she adds.
Sources/Resource
For more information about near miss reporting, contact:
- Mike Doering MBA, Executive Director, Pennsylvania Patient Safety Authority, Harrisburg. Telephone: (717) 346-0469. Fax: (717) 346-1090.
- Suzanne L. Broome, RN, Director, Blue Ridge Surgery Center, 10630 Clemson Blvd., Suite 200, Seneca, SC 29678. Telephone: (864) 482-5100. E-mail: sbroome@broa.com.
Pennsylvania patient Safety Authority web site: www.psa.state.pa.us. To find copies of past issues of Patient Safety Advisory, go to the web site and select "Advisories and related resources" on left navigational bar. Scroll down page to view titles of articles included in each issue. To find toolkits and other resources, click on the "Resources Associated with Patient Safety Advisory Articles" link included in the text at the top of the "Advisories and related resources" page.