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Reporting: It Matters  


A Patient Safety Authority (PSA) analyst noted a report describing the near-death of a newborn after the mother fell asleep holding the baby. Further analysis revealed dozens of reports of newborns falling across Pennsylvania, every year.

Because an individual facility may only experience one or two newborn falls annually, it would be nearly impossible to measure the true scope of the problem without a broader perspective. The analysis—the largest one to date—brought light to an otherwise hidden and life-threatening issue.

A few years ago, a facility called with a concern regarding misplacements of nasogastric feeding tubes. Several staff members (with decades of combined experience inserting tubes) were suddenly inserting them in patients’ lungs instead of their gastrointestinal tract, and they wanted to know if anyone else had reported the same issue. Two other facilities had.

A popular manufacturer stopped producing the enteral devices, forcing facilities to find an alternative quickly. This facility ordered a replacement of the same size and type, but communication of the change did not reach those who were placing the feeding tubes. The veteran staff continued to place the tubes as they always had—without realizing they were using a different product. Once told about the change, they commented the new tubes did seem less pliable and slicker than the previous ones.

Event reporting in Pennsylvania is more than a requirement. It’s a vital tool. Each event reported by an individual facility can be analyzed to see whether anything similar has transpired elsewhere—it likely has. That analysis can help prevent future recurrence.

What are you supposed to report in Pennsylvania? Probably more than you think.

In a recent survey of Pennsylvania nurses, physicians, pharmacists, and respiratory therapists, few were accurately able to identify reportable patient safety events.

Example 1: A patient arrives for back surgery. Afterwards, he can’t move his legs—not just until the anesthesia wears off but the next day and the day after that. Your patient is paralyzed from the waist down. Does this sound like a reportable patient safety event to you? It should.

However, almost 20% of surveyed nurses and physicians didn’t think so. 

Example 2: During labor, there is a delay in recognizing fetal distress, and the baby dies. Reportable? You bet. But one out of five respondents said no.

Not only does underreporting miss an opportunity to share critical information that could improve care for everyone, but it also puts facilities and clinicians at risk.

The Pennsylvania Department of Health can issue fines if facilities fail to meet their reporting requirements. And individual healthcare providers can be reported to their respective licensing boards.

What can we do? 

The knowledge gap—Every healthcare worker employed by or privileged at your organization is required to comply with your patient safety plan. Is your plan clear about what needs to be reported and how? The PSA can help educate your staff. Contact your patient safety liaison for assistance.

Fear of a lawsuit— Lawsuits occur because a patient was harmed, not because the harm was reported. Focus on the patient and their family and not the repercussions. What do they need now, in a month, or in a year?

Fear of investigation—The process is stressful. I get that. I remember the first time I had to go through an inspection by the Department of Health. I was 26 years old, a brand new director of nursing, and it was my second day on the job. I remember standing in a small office being grilled by three surveyors about quality-of-care issues I had inherited. I was so stressed I felt like I was going to faint.

Then, like from a scene in a movie, one of the lenses in my glasses literally popped out and fell onto the floor in front of me. Sweat rolled down my back. I’m sure at some point I cried. But they had a job to do. They had a responsibility to those residents, just like me. I learned over time to appreciate their perspective–not necessarily to like the process–but I understood where they were coming from. 

Fear of retaliation—It’s been 20 years since patient safety became an established discipline. How do you think news of someone who was harassed or fired for raising safety concerns would play out? If this is a concern in your organization, fix it.

What else? Time constraints. This is difficult because there are so many competing priorities. Make sure staff see the time spent reporting an event as valuable. Do you provide feedback on events after they’ve been reported– especially on appropriate changes? Do staff see the data used to drive quality improvement projects? While value doesn’t fix time constraints, it does make the time spent worthwhile. 

The events submitted to PSA matter. Clinical leadership, clinical staff, and I review every high harm event. We often follow up directly with patient safety officers to provide resources or to gain a better understanding of what happened. These events may trigger safety alerts, like our most recent on anticonvulsants, and they often prompt further analysis from our database to better understand the issue and to publish our findings.

All of this is to improve the care for the next patient. 

I encourage you to start thinking about the next wave in patient safety event reporting. How can we make the data more actionable while decreasing the burden on frontline providers? Remember when we implemented healthcare-associated infection (HAI) surveillance systems and revolutionized HAI reporting?

Are you thinking about or beginning to explore this type of advanced data mining for other patient safety events? If you are moving in this direction, I applaud you. You are leading the way.

In the meantime, identify hot spots for underreporting and improve them. Compare reported events with other internal sources (e.g., surgical complication logs; hospital-acquired condition coding; and departmental quality assurance logs, such as missed treatments in respiratory or dosage changes initiated by pharmacists).

We are in this together. Help us help all patients by committing to a culture that encourages reporting and puts patient safety first.

About this blog

Regina Hoffman serves as the  executive director of Pennsylvania’s Patient Safety Authority and editor-in-chief of Patient Safety, its award-winning journal.  Ms. Hoffman was recognized by Becker’s Hospital Review as one of the top 50 experts leading patient safety in both 2018 and 2020. This blog serves as a source for her to share her insights in patient safety and leadership with Pennsylvania’s healthcare leaders.


***​ The views and opinions expressed at or through this blog are the opinions of the author alone and may not reflect the opinions or positions of the Patient Safety Authority or the Commonwealth of Pennsylvania, nor do these views represent in any way medical or legal advice. ​ 

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