The nurses at the Crozer Endoscopy Center at Brinton Lake implemented an action plan to complete risk event reports for multiple events that were not captured previously due to lack of knowledge, fear of punishment, or other reasons. Their second goal was to have more people reporting these events.

Education was given to the nursing staff, and a list of possible events was posted at every nurse’s station. At the end of the day, checks were completed to see whether any events were overlooked so as not to miss reporting one. The results were very successful. The type of event being reported went from two to five types, and the number of events per month went from one to 16 (some being procedure not completed due to poor preps). The number of nurses reporting went from one to eight nurses (there are only nine nurses in the department.) A list of the reporting nurses for that month is posted on the information board as positive reinforcement. The nurses feel safe in being transparent in event reporting now. Next, the facility will take this data to see how to improve the patient prep process.