Did you know that Pennsylvania healthcare facilities are part of one of the largest and most cutting-edge learning systems in the United States?

What is a learning system or learning organization? Simply, it is an organization that continually collects data that is then leveraged to effect policy and process change to improve safety.

In September 2020, the National Steering Committee released its National Action Plan to Advance Patient Safety. I had the honor and privilege of working with a remarkable group whose entire focus was on the importance of learning systems.

The concept of a learning organization was critical because we knew it would not only improve patient safety but also impact each additional part of the plan: culture, leadership and governance, patient and family engagement, and workforce safety.

Learning organizations constantly learn from the information they gather. That information can—and should—come from various sources, including healthcare workers and patients. But what happens when the data stream is tapped out?

Even in a place like Pennsylvania where reporting patient safety events is mandated by law, accounts from healthcare workers related to safety events are not consistently reliable or thorough.

While some staff members may just refuse to report events, they very likely are the small minority. There are several real and perceived barriers to reporting. Here are my unofficial top three:

1. Knowledge — There is a continual knowledge gap: new people entering the field, healthcare workers relocating from other states and countries, and competing educational priorities. Not knowing what needs to be reported isn’t an excuse but it is a reality. Early results of a quick survey showed that even in fairly clear scenarios—like a patient experiencing permanent paralysis after a back surgery—more than 20% of clinicians who responded didn’t recognize this as a reportable event. Clearly, we have work to do. Being able to recognize risk and what constitutes a patient safety event is foundational to improving safety. You can’t fix a problem if you don’t even recognize it exists.
2. Fear — Healthcare workers fear many things when it comes to reporting. Some common fears, whether based on real experience or perceived (from a long-standing culture of blame), include fear of job loss, fear of retaliation, fear of reputation loss, fear of a lawsuit, fear of license loss, and fear of public shame. It amazes me how we can wonder why healthcare workers aren’t keen on reporting mistakes, yet when they do, we shame or reprimand them as a first line of response.
3. Time — There will never be enough of it. So, what can we do about it? Especially when some event reporting systems are clunky and difficult to use or initial staff reports are still being collected on paper.

We've been tackling knowledge, culture, and efficiency for years and have seen incremental improvement in reporting. Keeping the same approach will likely continue to see only small increases.

If we were creating a new method of event reporting, what would we do differently? Would we rely largely on staff to “see something, say something”?

Just as we leverage technology to support staff in other areas—robot-assisted surgeries, clinical decision support, healthcare-associated infection surveillance—we can implement systems to not only identify harm, but also predict it.

Several organizations, including the Patient Safety Movement Foundation and the Jewish Healthcare Foundation, are helping coordinate a push for a national patient safety authority which could provide the infrastructure for a national patient safety learning system. (Check out this recent panel of national experts discussing the use of advanced data analytics to support such a system.)

I started by asking if you knew that Pennsylvania is a leader in this arena. My next question is how will we continue to be in the forefront?

The technology is available and evolving as I type this. If your organization is an “early adopter” of a virtual patient safety monitoring system, or if you are considering implementing one in the near future, please reach out to me at patientsafety.pa.gov. I am very interested in hearing about your experience.