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

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. 

Safety reporting system solutions:

  • Simplify the level of detail you ask for in the first report.
  • Match the data collection with the review process.
  • Improve integration with the EHR to launch event forms and ease and improve patient data capture. 

Client challenge #2: I am overwhelmed by the number of reports/we don’t have enough resources to manage the reports. 

Safety reporting system solutions:

  • Define a risk-analysis method that helps prioritize patient safety reports that need immediate analysis.
  • Trust the methodology to push some events to a track/trend category and periodically audit the category to adjust your methodology accordingly. This process should improve relevance detection over time. 

Client challenge #3: Reported events go into a black hole. 

Safety reporting system solutions:

  • Provide meaningful feedback for specific events and build overall team awareness of safety concerns through real-time activity tracking and avoidance of generic user accounts.
  • Engage the entire staff in the improvement cycle to foster an appreciation for the enterprise investment in eliminating harm.

Client challenge #4: We have lots of patient safety reports, but we are not seeing improvements and/or the same issues happen over and over again. I don’t know how to analyze all this data to get real insights. We look at cases one by one and have trouble finding trends. 

Safety reporting system solutions:

  • Design a triage process that can detect common themes and quickly classify them for aggregate analysis.
  • Conduct periodic common cause analysis to help teams identify patterns.
  • Use tools to evaluate the strength of action items to confirm that analyses are informing stronger actions.
  • Align safety with your process improvement team efforts to ensure the appropriate improvement occurs. 

Client challenge #5: It's unclear who is responsible/accountable—what needs to be fixed locally vs. at a higher or broader level. 

Safety reporting system solutions:

  • Establish processes to ensure multidisciplinary root cause analyses inform meaningful change.
  • Manage action plans using a defined daily management process that delineates when a plan requires review by a central committee; identifies items that can be implemented within a team; and determines what can be done locally vs. what requires escalation.
  • Evolve your process from spreadsheets and email to a central action planning system to help all stakeholders understand the pace and magnitude of change in your organization.
  • Manage recommendations and prioritize efforts that set teams up for success and ensure positive momentum over time.

Integrating safety reporting processes such as these into a comprehensive learning system grounded in the principles of high reliability allows organizations to build the kind of high-value safety program needed to drive toward zero harm.

1. Agency for Healthcare Research and Quality. Accessed July 23, 2019. [2015b] 

2. Farley DO, Haviland A , Champagne S, Battles JB, et al. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care. 2008; 17: 416-423.

3. Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15:39-43.

4. Macrae C. The problem with incident reporting. BMJ Qual Saf. 2016; 25: 71-75. 

5. Sexton JB, Adair KC, Leonard MW, et al. Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout. BMJ Qual Saf. 2018;27:261-270.

About the author

As Chief Safety and Transformation Officer, Dr. Gandhi, MPH, CPPS is responsible for improving patient and workforce safety, and developing innovative healthcare transformation strategies. She leads the Zero Harm movement and helps healthcare organizations recognize inequity as a type of harm for both patients and the workforce. Dr. Gandhi also leads the Press Ganey Equity Partnership, a collaborative initiative dedicated to addressing healthcare disparities and the impact of racial inequities on patients and caregivers. Before joining Press Ganey, Dr. Gandhi served as Chief Clinical and Safety Officer at the Institute for Healthcare Improvement (IHI), where she led IHI programs focused on improving patient and workforce safety.

Profile Photo of Dr. Tejal Gandhi, MPH, CPPS