In 2012, Chicago-based Presence Health began holding meetings called “report-outs” at its 12 hospitals to identify systemic problems that could hinder the delivery of high-quality care and possibly result in patient-safety mishaps. Such issues are identified by frontline staff and brought to the attention of leadership. During weeklong “breakthrough” events, staffers work rapidly to come up with solutions, and changes are implemented by the end of that week.
Systemic flaws that could or do lead to patient harm remain rampant in healthcare settings. But, unlike in aviation and other industries, those landmines are routinely ignored or put aside at many hospitals until they result in disastrous outcomes such as patient injuries or deaths. Root-cause analyses are seldom done for near misses.
That's “a superficial and unsophisticated way to run a safety system,” said Dr. James Bagian, director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan.
Dodging a bullet should be looked at as an opportunity to fix a potential problem in advance, according to Bagian and a team of multidisciplinary safety experts in a National Patient Safety Foundation report released last week titled, RCA²: Improving Root Cause Analyses and Actions to Prevent Harm.
The report urges hospitals and other healthcare providers to approach close calls with the same or greater rigor as they do when a major safety event occurs. No harm does not mean no foul, it said.
Though the term “culture of safety” has become commonplace in healthcare, making it a widespread reality has proved elusive, in part because establishing a safety culture involves hard, continuous work and can challenge the status quo.
One issue the NPSF report raises is that safety-event reporting systems are often designed to log incidents that have already happened, rather than looking at problems that were caught before an adverse event occurred.
Even getting hospital staff to use existing incident-reporting systems can be a challenge. Such reports captured only about 14% of the safety events experienced by discharged Medicare beneficiaries, and they were frequently not reported because of staff misperceptions about what constituted harm, a 2012 report from HHS' Office of Inspector General found.
The incident-reporting concept “has not caught on,” said Dr. Ethan Fried, associate professor of medicine at the Hofstra North Shore-LIJ School of Medicine. He was part of the advisory board that developed the Near Miss Registry, an online anonymous reporting system run by the American College of Physicians' Patient Safety Organization.
