Patient safety event reporting: High reliability drives progress toward zero harm

March 11, 2022

Dr. Tejal Gandhi, MPH, CPPS

Coauthored by Mike Personett, SVP, Safety and Reliability.

Patient safety is recognized as the foundation of high-quality care, and the goal of zero harm has been widely adopted across healthcare systems. While awareness and goal setting are essential, real inroads in advancing patient safety require optimized patient safety reporting systems that more reliably drive actions that reduce harm.

Patient safety reporting systems identify, collect, report, and analyze safety events and near misses. To be optimally effective, these programs must be part of a comprehensive learning system built on the principles of high reliability in which safety events are seen as opportunities for improvement. Such patient safety reporting systems use data to inform action, include reliable feedback loops to enable learning and improvement, and are capable of measuring their own impact.

As in other complex, high-stakes industries, safety reporting in healthcare has been used as a way to measure serious safety event rates and as a measure of culture change, where increased reporting can indicate a culture that prioritizes transparency and improvement over punishment. However, issues exist with event reporting in healthcare. In particular, the event reporting systems employed by many healthcare organizations generate thousands of reports each year that require review, triage, and action—and yet capture a small proportion of relevant events.¹

In one study, researchers concluded that most of the 1,600+ U.S. hospitals evaluated didn’t maintain effective patient safety event reporting systems.² In addition to lack of physician reporting, most hospitals surveyed in the study didn’t have robust processes for analyzing and acting upon aggregated event reports. Failure to receive feedback after reporting an event is also a commonly cited barrier to patient safety event reporting by both physicians and allied health professionals.³ Without an effective learning system, patient safety event reporting requires too much review time by team leaders, is expensive, can generate an overwhelming volume of data, and will likely not meet the goal of eliminating harm.

In an article contrasting event reporting in healthcare and other high-risk industries, such as aviation,⁴ the author proposed that event reporting systems in healthcare have placed too much emphasis on collecting reports instead of learning from the events that have been reported. In addition, front-line clinicians and clinical managers often fail to receive critical information about adverse events and trends—learnings that could lead to changes to reduce future harm events.⁵

Breaking down these barriers requires moving away from a focus on patient safety reporting systems as mechanisms for simply collecting data and toward their integration as key components of a high reliability operating system that optimizes learning and improvement in patient safety solutions.

Below, we describe common user challenges with current patient safety reporting systems and processes as well as patient safety solutions supported by the Press Ganey High Reliability Platform™ (HRP).

Client challenge #1: Patient safety report submission takes too much time.