Reporting errors improves perceptions of safety and may reduce incidents
When adverse events are documented, perceptions of safety improve and incidents may decrease in multisite clinical practices. This year-long study focused on the workflow of a Radiation Oncology department and found a strong correlation between implementing a Conditions Reporting System and increasingly positive responses to staff surveys that focused on the culture of safety within the department.
After 1 year, the study resulted in an increasingly open and healthy culture. Responses improved on staff surveys focused on safety. During the duration of the study, staff in all divisions and across all steps in the Radiation Oncology workflow participated in reporting incidents. The safety culture was measured with the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey, which is a tool commonly used to assess the safety culture of a hospital or specific unit within a hospital over time.
When the research team compared the results of the survey from the onset of the study to those gathered 1 year later, improvements occurred in 11 of the 13 categories that pertain to a safe and open environment. The positive findings have led to the research team planning to continue to institute policies and procedures that will ensure that low-level errors are addressed so they do not escalate into serious problems that could harm patients.
“By providing a conditions reporting program and encouraging our entire staff to be part of the process of improving patient safety, we're reinforcing that safety is a top priority,” said Stephen M. Hahn, MD, Henry K. Pancoast Professor of Radiation Oncology, and chair of the Department of Radiation Oncology at the Perelman School of Medicine at the University of Pennsylvania. “What we've learned from reporting events has already led to a number of changes to departmental policies, procedures, and workflow. Ultimately, by reporting and investigating incidents, our faculty and staff are more confident in the care they provide and we're better able to identify any holes in our processes. Moving forward, we hope these systems will aid in preventing adverse events.”This research was presented at the American Society for Radiation Oncology (ASTRO) 54th Annual Meeting in Boston.