Changing flags, potholes to reporting errors, misses
It seems everyone is saying they want staff members to report errors and near misses more freely, but actually achieving that goal can be difficult. An innovative program at The Baylor Medical Center in Grapevine, TX, says it has increased reporting tenfold by encouraging staff to "plant a flag" when coming across a "pothole in the road."
The hospital uses the pothole analogy to encourage staff to actually do something when it sees a potential medical error, says Traci Atherton, RN, vice president of clinical support. She shares risk management duties with Julie Gunderson, RN, director of quality management. Atherton says the hospital distributed buttons to employees that say, "I plant flags."
"An adverse event is like a pothole. You can either drive by and not do anything about it, or you can plant a flag so it can be fixed, or you can drive into the pothole," Atherton says. "You plant a flag so the right people can get involved before it ever reaches a patient or family member. That’s where we saw the numbers increasing because they told us about the potholes. They were planting flags."
The effort is paying off. In 1999, staff and physicians reported about 15 errors or near misses each month. Now that number is up to 150 per month.
Major culture change
The pothole analogy came about as part of an overall culture change initiated in 1999, with an emphasis on making quality, safety, and customer service everyone’s responsibility. Another big part of the effort was instituting a reward system for employees who step forward with concerns about system weaknesses or to report actual errors.
The rewards range from a free cookie in the cafeteria, to free lunches and coupons for movie tickets. To foster even more reporting, the hospital sponsors competitions between departments to see who can increase reporting the most in a given period. To make the competition fair, success is measured by the percentage increase in reporting rather than just raw numbers.
"If I’m in the emergency department, I’m going to have more opportunity to identify errors and problem than in someone in registration," Atherton says. "Doing it by percentage of increase reflects how much that department is improving. The department with the biggest increase gets $150 for a pizza party."
Baylor implemented those techniques right away, and Gunderson says they "helped jump-start the culture change. They saw that when they reported, someone did something."
Everyone is a risk manager at Baylor
The hospital also put two vice presidents in charge of the effort to increase reporting, naming them as the hospital’s patient safety officers. With two top leaders heading the effort, employees knew their concerns would get to the top quickly and that action be could be taken.
Another strategy at Baylor is what Gunderson and Atherton call "rounding with a purpose." The safety committee and other hospital leaders regularly conduct rounds at the hospital to check on safety issues and communicate with staff, but they make sure there is a purpose to the exercise. Some hospital safety committees conduct rounds but without a concerted effort to find issues and see what’s going on in the facility, they say.
"We’re not just walking around chatting. We’re actually digging deep," Atherton says. "We want to know what are the issues that frustrate you and what keeps you from doing your job well. We recognize that every staff person comes in with the intention of doing a good job that day. There are processes and resource needs that prevent them from doing that."
Baylor also emphasizes that every staff member is a risk manager, one reason no one at the hospital actually has that title. "We all wear the risk hat, instead of just Traci and me," Gunderson says. "We want everyone to be an owner because when you’re an owner you’ll clean up your house better than if you’re a renter."
The hospital also has a committee that helps employees and physicians when they commit a medical error, a step that Atherton says is often overlooked. The employee and physician can suffer great emotional stress after an error, and all too often they are left on their own while the hospital investigates and responds to the error. The committee provides counseling and may authorize a couple days off to rest and it can refer the employee or physician on to more in-depth counseling.
Soon after starting the initiative, Baylor set up an on-line tool for reporting errors. Previously, the hospital had five different forms that employees used to report errors and system problems, but employees complained that the forms were confusing and no one knew when to use each form. So now the hospital has an on-line form that uses a decision tree to walk the user through all the questions necessary collect the desired information. Staff are much happier with the on-line reporting system, Atherton says. "People can report anonymously, but we encourage them to identify themselves so we can go back to them," she says. "We surveyed staff and very few felt like reporting anonymously was important. Most give their names because they want to be a part of the solution."
Ask for feedback, and be ready to respond
Gunderson notes that surveying staff and physicians is a big part of the risk management effort at Baylor, with a constant effort to see what is working and what isn’t. The survey often asks if a policy or idea is punitive, so the leaders can get a feel for how it is being perceived on the front lines. What sounds good to hospital executives might be perceived very differently on the nursing units.
"But when you ask, you have to act on the answers," Gunderson says. "You’re defeating the purpose if you don’t do anything in response to what you find out. People will get the idea that you’re just all talk, and that’s exactly what you don’t want."
So far, the three years of effort have achieved a significant culture change at Baylor and resulted in measurable improvements in many areas. Medication errors have been reduced by breaking each into components and by having a multidisciplinary team look for weak points in the system that allowed the error to occur. Medications that sound alike or look alike are stored far apart from each other to minimize confusion. Falls have been reduced by a concerted effort to assess patients, flag their charts if they are at risk for falls, and to educate ancillary services (like X-ray and lab technicians) and family about the risk of falls.
"We continue to see an increase in our reporting numbers, which is good," Gunderson says. "Error reporting is on the rise, which means we are free to report more, not that we’re making more errors."
An innovative program at The Baylor Medical Center in Grapevine, TX, has increased reporting of errors and near misses tenfold by encouraging staff to plant a flag when coming across a pothole in the road. The hospital uses the pothole analogy to encourage staff to do something when it sees a potential medical error.
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