Establishing a family-initiated safety reporting program

Denise HudsonAnnemarie Taylor

We all know the stats:

• Adverse events occur in 7.5% of hospital admissions• 70,000 preventable adverse events• 9,000-24,000 preventable deaths• 1.1 million additional hospital days • Comparable to similar health systems

Adverse Events in Canadian Hospitals

Baker, R., Norton, P. et al (2004)

How can we be safer?

• Despite significant effort by care providers, there is little evidence of real improvement

• One source of experience and expertise that remains largely ignored is that of the patient and family!

Family-initiated reporting?

Research conducted at BC Children’s

1. Literature Review on patient/family reporting

2. Human Factors Evaluation of web-based tool for family reporting using BC PSLS

3. Bedside Observer Project: For one year, parents of patients discharged from a pediatric surgical ward at BC Children’s were offered use of the family reporting system to identify safety concerns

Identification by families of pediatric adverse events

and near misses overlooked by health care providers

Daniels, J., Hunc, K. et al (2011)

Safety event classification

• Type– Medication– Equipment– Complications– Miscommunication between staff– Miscommunication between family and staff

• Degree of harm• Likelihood of recurrence• Quality of information in report

1. Are patients and families able to

reliably report safety events?a. Yes

b. No

1. Are patients and families able to

reliably report safety events?a. Yes

b. No

1. Are patients and families able to

reliably report safety events?a. Yes

b. No• Family reporting found reliable in all (3) studies

where corroboration was conducted• However…too few studies in areas too diverse to

allow definitive conclusions

1. Of 544 families asked, howmany reported concerns?

a. 121

b. 221

c. 321

d. 421

1. Of 544 families asked, howmany reported concerns?

a. 121

b. 221

c. 321

d. 421

1. Of 544 families asked, howmany reported concerns?

a. 121

b. 221

c. 321

d. 421• 321 families (59%) reported concerns – significantly

higher than classic adverse event rate in hospitals!• Weissman (2008) found patients identify twice the

incidence of adverse event found by chart review

3. How many of the 321 reports were judged by two reviewers to be actual safety events?

a. 77

b. 177

c. 257

d. 307

3. How many of the 321 reports were judged by two reviewers to be actual safety events?

a. 77

b. 177

c. 257

d. 307

3. How many of the 321 reports were judged by two reviewers to be actual safety events?

a. 77

b. 177

c. 257

d. 307• 59 % of families reported a safety concern and more

than half of the reports were actual safety events• The family reporting system detected a 30% safety

event incidence on the study ward

Examples

“Nurse hung bag of meds for IV that my daughter was allergic to, despite the large sign on the door and allergy warning on her bracelet.”

“Wound developed due to an

intravenous line.”

“Ulcer due to meds caused bleeding.”

4. Which was the most frequent type of event reported?a. Medication problem

b. Equipment problem

c. Complication of care

d. Miscommunication between staff

e. Miscommunication between family and staff

4. Which was the most frequent type of event reported?a. Medication problem

b. Equipment problem

c. Complication of care

d. Miscommunication between staff

e. Miscommunication between family and staff

4. Which was the most frequent type of event reported?a. Medication problem

b. Equipment problem

c. Complication of care

d. Miscommunication between staff

e. Miscommunication between family and staff• Parent reports are consistent with literature

surrounding adverse events (Kitch 2009)• Medication and communication problems

predominate!

Types of family reports

5. Will parents only report anonymously?a. Yes

b. No

5. Will parents only report anonymously?a. Yes

b. No

5. Will parents only report anonymously?a. Yes

b. No• 81 % of parents voluntarily provided name and

contact information• AND…of the parents who left their names, 80%

agreed to be contacted to participate in future efforts to improve patient safety

What didn’t happen

• Care provider reporting patterns and volume did not change

• Families did not use the system to lodge spurious or personal complaints

• There was very little overlap between care provider reports and family reports

Key points

• Patients and families can provide timely, accurate and important information about the safety of care

• Patients and families report safety incidents that would otherwise go undetected

• Patients and families are highly motivated to report errors or problems in their care

…so…

Where to now?

Forward!

• Application for funding to develop full-scale family-initiated reporting program at BC Children’s was unsuccessful

• Solid support from BC Children’s senior leadership to move forward

• Task Force formed and thinking hats on!

de Bono’s Six Thinking Hats

Research-based evidence, support from leaders, aligns with strategic priorities, patient role

Gives the family a voice, increases surveillance, offers new lens, early detection, systematic approach

Who will do the work? Staff are busy! How to close the loop with families? No resources. Need translation. Blurs with satisfaction surveys. Too many surveys! Volunteers would need management and training.

de Bono’s Six Thinking Hats

May save lives, improve care, families will feel empowered, listened to, the right thing to do. “It’s a no-brainer!”

Information package on admission to engage families, tablet reporting, TV station, e-learning, phone-in, same floor or not? Develop targeted volunteer program, involve parents as partners.

Explore potential sources of support to define scope of work and approach. Start small, use PDSA approach.

Your turn…