How to engage healthcare workers to report incidents or medical errors ?

How to engage
healthcare workers to report
incidents or medical errors?
?
A/Proff LLe Thi Anh
A/P
A h Thu,
Th MD PhD
Chief of Risk Management Unit
Cho Ray Hospital, HCMC, Vietnam
Engage healthcare worker to report incidents…
Reporting incidents or medical
errors: an important task
Learning from errors
to prevent harm
Serious injuries
or death
1
Minor injuries
29
Near misses/ Latent factors
300
Heinrich pyramid
Reporting incidents or medical
errors: an important task
Learning from errors
to prevent harm
Serious injuries
or death
1
Minor injuries
29
Near misses/ Latent factors
300
Heinrich pyramid
Voluntary reporting incidents or
medical errors is required
Incidents can occur in at least 3% of all patients
patients
Require healthcare worker to report incidents voluntary
Voluntary incident reporting system plays a key role in
risk
i k managementt and
d improving
i
i patient
ti t safety
f t
Panzica M et al , Unfallchirurg 2011 Sep;114(9):758-67.
Vincent et al. NHS of England and Wales 2001
Challenges
• Low number of incident
reporting:
Hospital staff did not
report 86 % of events
• Voluntary incident
reporting yielded a much
lower reporting rate of
adverse drug events
reported in the
literature.
Barriers
‘Culture of blame’
• Guilt
G ilt or meting
ti outt punishment
i h
t
• Feared legal
g repercussions
p
• Fear of disciplinary action
Sue M Evans,
Evans, Qual Saf Health Care 2007
Neuspiel DR, Agency for Healthcare Research and
Q lit 2008 Aug.
Quality;
A
Barriers
• Errors are an ‘inevitable’ and ppotentiallyy
unmanageable feature
• Time constraints
• Incident reporting is ‘pointless ’
• Lack
L k off feedback
f db k
• Did not know what or how to report
p
Sue M Evans
Evans,, Qual Saf Health Care 2007
Neuspiel DR, Agency for Healthcare Research and Quality;
2008 Aug.
Barriers
Nurses tend to
report more
frequently than
doctors
Evans SM et al; Qual Saf Health Care , 2006 Feb;15(1):39-43.
Barriers
Western and Asian culture
http://www.vincentchow.net/2004/western-asian-culture-comparison
Barriers
Western and Asian culture
http://www.vincentchow.net/2004/western-asian-culture-comparison
An example
In an outpatient department, Nurse A called:
Ms An
An, please come in
in”
“Ms
A woman said “Yes”, stood up and was told to
enter into examination room.
room
Doctor informed her that she is pregnant and say
congratulation The woman is very surprised and
congratulation.
said “it is impossible, doctor!”
“Are
Are you Le An?”
An? “No
No I’m
I m not, I am Nguyen An”
An
Nurse A shouted at her “Oh dear, I did not call
you, why did you enter the room!”
room!
• Do you think the nurse will report this
situation as an incident?
• The reason why Nurse A does not report
this incident ?
• How to persuade staff to report such
incidents?
How to engage
healthcare worker
to report incidents
voluntary?
y
Multi--approach
Multi
O direction
One
di ti
Behaviour change
Motivation is the art of getting people
to do what yyou want them to do
because they want to do it
Dwight D. Eisenhower 1953-61
Reportt and
R
d you
will get bonus
I really like to
report
If you do not
report, you will be
punished
I donot really like
to report
Negative motivational methods
Intern
nal
Some
eone else
e motivate
es you

Within the pers
son
Exterrnal
Positive motivational method
What is
motivation of
healthcare
workers?
Job satisfaction
White-collar workers
Blue-collar workers
1. interesting work
2 opportunity to develop special
2.
abilities
3. enough information
4 enough
4.
eno gh authority
a tho it
5. enough help and
equipment;
6 friendly
6.
f i dl and
d helpful
h l f l coworkers
k
7. opportunity to see results
of work
8. competent supervision
9. responsibilities clearly defined
10. good pay
1. good pay
2 enough help and equipment
2.
3. job security
4. enough information
5 interesting
5.
inte esting work
ok
6. friendly and helpful
coworkers
7 responsibilities
7.
ibiliti clearly
l l
defined
8. opportunity to see results of
workk
9. enough authority
10. competent supervision
Sanzotta , 1977
5 steps to change doctors’
behaviours
1 Investigation working‘s environment
1.
2 Understand current behaviours
2.
3. Choose behaviours required to be
changed
4. Conduct strategies to change
5. Enhancing support
5.
Cook 2004
5 strategies
g
to change
g doctors’
behaviours
1. Supply detailed knowledge
2. Surveillance and feedback
3. Leadership
3.
4 Reminder system
4.
5. Supply documents
Cook 2004
Conditions needed for behavior changes
Products &
Tools
Promotion
-Facilities
Facilities
Mass media
-Mass
-System
-Activities & events
-Training
Supportive
Environment
-Leader support
-Financing
Financing
Increasing the likelihood of
behaviour change
Products &
Tools
P
Promotion
ti
Increased
likelihood of
behavior
change
h
Supportive
Environment
When all the
conditions are in
place in the same
place at the same
time it increases
time,
the likelihood of
adopting and
maintaining a
practice.
i
26
Conditions needed for engaging
healthcare workers to report incidents
Training
M
Mass
media
di
What are incidents?
-Poster
How important?
-Pamphlet
P
hl
How to report?
-Intranet
Tools
Good reporting
system
Easy and simple
Supportive
environment
Leader support
Bonus for reporting
p
g
Feedback given to reporter
27
Conditions needed for engaging
healthcare workers to report incidents
Training
M
Mass
media
di
What are incidents?
-Poster
How important?
-Pamphlet
P
hl
How to report?
-Intranet
Tools
Good reporting
system
Easy and simple
Supportive
environment
Leader support
Bonus for reporting
p
g
Feedback given to reporter
28
Training
• Should be continuing education
• Can be a part of patient safety course
• Evidences showed that training can have
immediate and longlong-term positive effects on
knowledge, attitudes, skills and practices in
incident reporting
Jansma JD.
JD BMC Health Serv Res,
Res 2011 Dec 12;11:335.
12;11:335
Training
• Importance of report incidents
• Purposes and aims of incident reporting
• Clarifying
y g what to report:
p
clear definition
of reportable incidents
• Clarifying how to report
• Designating specific members of staff
with responsibility for reporting
reporting.
• Making exciting to report
Levels of incidents
Level Content
Example
1
Errors occur but are not
done in patients
Prepared wrong medicine
but recognized before
giving
g
g it to p
patient
2
Errors occur, are done in
patients, but caused
minor
i
effects
ff
3
Errors occur
occur, are done in
patients, caused
moderate effects
Withdraw blood for wrong
patient but recognized
b f
before
sending
di to the
h llab:
b
blood taken repeatly
Leave gauze
gauze, instruments
in patients but discovered
before patients leave
operating
ti room
Levels of incidents
Level Content
Example
4
Errors occur and caused Operated wrong patient,
severe effects
or wrong site; causing
injures for patients
5
Errors occur and caused Used wrong dose or
death
drugs, wrong blood
group; causing patients
‘death
Reporting System
• the process needs to be simplified
– clear definitions for classifications
– structured framework for contributory
factors
• designated staff to record incidents
• providing the possibility to report
anonymously
l
• providing feedback
Reporting System
• A WebWeb-based electronic reporting system can be
helpful
- report incident events anonymously and
confidentially
- allows incidents to be updated on the
database locally
• The studies showed a significant improvement in
incident reporting rates after the introduction of
the new electronic reporting system.
Parmelli .E,
E Cochrane Database Syst Rev.
Rev 2012 Aug 15;8:CD005609.
15;8:CD005609
Kuo YH. Comput Inform Nurs. 2012 Jul;30(7):386-94.
Supportive environment
• Creating an incident reporting culture
• Feedback given to reporters
• Feedback and reassurance to staff about
the nature and purpose of systems
systems.
• Leadership support
– Bonus
B
ffor good
d reporter
t
Western and Asian culture
http://www.vincentchow.net/2004/western-asian-culture-comparison
Method to ensure maintaining compliance
National Reporting and Learning System (NRLS) Quarterly
Data Workbook up to December 2011
Engage healthcare worker to report incidents…
Thank you
y
S
September 13 & 14, 2012 ●
b
3&
20 2 Melia
li Hotel ●
l Hanoi, Vietnam
i i
Assoc. Prof. Le Thi Anh Thu
Chief of Risk Management Unit, Cho Ray Hospital letathu@yahoo.com