How to engage healthcare workers to report incident or medical errors
How to engage healthcare workers to report incident or medical errors
How to engage healthcare workers to report incident or medical errors
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<strong>How</strong> <strong>to</strong> <strong>engage</strong><br />
<strong>healthcare</strong> <strong>w<strong>or</strong>kers</strong> <strong>to</strong> <strong>rep<strong>or</strong>t</strong><br />
<strong>incident</strong>s <strong>or</strong> <strong>medical</strong> err<strong>or</strong>s?<br />
A/P f L Thi A h Th MD PhD<br />
A/Prof Le Thi Anh Thu, MD PhD<br />
Chief of Risk Management Unit<br />
Cho Ray Hospital, HCMC, Vietnam
Engage <strong>healthcare</strong> w<strong>or</strong>ker <strong>to</strong> <strong>rep<strong>or</strong>t</strong> <strong>incident</strong>s…
Rep<strong>or</strong>ting <strong>incident</strong>s <strong>or</strong> <strong>medical</strong><br />
err<strong>or</strong>s: an imp<strong>or</strong>tant task<br />
Learning from err<strong>or</strong>s<br />
<strong>to</strong> prevent harm<br />
Serious injuries<br />
<strong>or</strong> death<br />
1<br />
Min<strong>or</strong> injuries<br />
29<br />
Near misses/ Latent fac<strong>to</strong>rs<br />
300<br />
Heinrich pyramid
Rep<strong>or</strong>ting <strong>incident</strong>s <strong>or</strong> <strong>medical</strong><br />
err<strong>or</strong>s: an imp<strong>or</strong>tant task<br />
Learning from err<strong>or</strong>s<br />
<strong>to</strong> prevent harm<br />
Serious injuries<br />
<strong>or</strong> death<br />
1<br />
Min<strong>or</strong> injuries<br />
29<br />
Near misses/ Latent fac<strong>to</strong>rs<br />
300<br />
Heinrich pyramid
Voluntary <strong>rep<strong>or</strong>t</strong>ing <strong>incident</strong>s <strong>or</strong><br />
<strong>medical</strong> err<strong>or</strong>s is required<br />
Incidents can occur in at least 3% of all patients<br />
Require <strong>healthcare</strong> w<strong>or</strong>ker <strong>to</strong> <strong>rep<strong>or</strong>t</strong> <strong>incident</strong>s voluntary<br />
Voluntary <strong>incident</strong> <strong>rep<strong>or</strong>t</strong>ing system plays a key role in<br />
risk ik management and di improving i patient t safety<br />
ft<br />
Panzica M et al , Unfallchirurg 2011 Sep;114(9):758-67.<br />
Vincent et al. NHS of England and Wales 2001
Challenges<br />
• Low number of <strong>incident</strong><br />
<strong>rep<strong>or</strong>t</strong>ing:<br />
Hospital staff did not<br />
<strong>rep<strong>or</strong>t</strong> 86 % of events<br />
• Voluntary <strong>incident</strong><br />
<strong>rep<strong>or</strong>t</strong>ing yielded a much<br />
lower <strong>rep<strong>or</strong>t</strong>ing rate of<br />
adverse drug events<br />
<strong>rep<strong>or</strong>t</strong>ed in the<br />
literature.
Barriers<br />
‘Culture of blame’<br />
• Guilt <strong>or</strong> meting out punishment<br />
• Feared legal repercussions<br />
• Fear of disciplinary action<br />
Sue M Evans, Qual Saf Health Care 2007<br />
Neuspiel DR, Agency f<strong>or</strong> Healthcare Research and<br />
Quality; 2008 Aug.
Barriers<br />
• Err<strong>or</strong>s are an ‘inevitable’ and potentially<br />
unmanageable feature<br />
• Time constraints<br />
• Incident <strong>rep<strong>or</strong>t</strong>ing is ‘pointless ’<br />
• Lack of feedback<br />
• Did not know what <strong>or</strong> how <strong>to</strong> <strong>rep<strong>or</strong>t</strong><br />
Sue M Evans, Qual Saf Health Care 2007<br />
Neuspiel DR, Agency f<strong>or</strong> Healthcare Research and Quality;<br />
2008 Aug.
Barriers<br />
Nurses tend <strong>to</strong><br />
<strong>rep<strong>or</strong>t</strong> m<strong>or</strong>e<br />
frequently than<br />
doc<strong>to</strong>rs<br />
Evans SM et al; Qual Saf Health Care , 2006 Feb;15(1):39-43.
Barriers<br />
Western and Asian culture<br />
http://www.vincentchow.net/2004/western-asian-culture-comparison
Barriers<br />
Western and Asian culture<br />
http://www.vincentchow.net/2004/western-asian-culture-comparison
An example<br />
In an outpatient department, Nurse A called:<br />
“Ms An, please come in”<br />
A woman said “Yes”, s<strong>to</strong>od up and was <strong>to</strong>ld <strong>to</strong><br />
enter in<strong>to</strong> examination room.<br />
Doc<strong>to</strong>r inf<strong>or</strong>med her that she is pregnant and say<br />
congratulation. The woman is very surprised and<br />
said “it is impossible, doc<strong>to</strong>r!”<br />
“Are you Le An?” “No I’m Im not,IamNguyenAn”<br />
Nurse A shouted at her “Oh dear, I did not call<br />
you, why did you enter the room!”
• Do you think the nurse will <strong>rep<strong>or</strong>t</strong> this<br />
situation as an <strong>incident</strong>?
• The reason why Nurse A does not <strong>rep<strong>or</strong>t</strong><br />
this <strong>incident</strong> ?
• <strong>How</strong> <strong>to</strong> persuade staff <strong>to</strong> <strong>rep<strong>or</strong>t</strong> such<br />
<strong>incident</strong>s?
<strong>How</strong> <strong>to</strong> <strong>engage</strong><br />
<strong>healthcare</strong> w<strong>or</strong>ker<br />
<strong>to</strong> <strong>rep<strong>or</strong>t</strong> <strong>incident</strong>s<br />
voluntary?
Multi-approach<br />
One direction
Behaviour change
Motivation is the art of getting people<br />
<strong>to</strong> do what you want them <strong>to</strong> do<br />
because they want <strong>to</strong> do it<br />
Dwight D. Eisenhower 1953-61
Positive motivational method<br />
<br />
Exter rnal<br />
Some eone else e motivate es you<br />
Rep<strong>or</strong>t and you<br />
will get bonus<br />
If you do not<br />
<strong>rep<strong>or</strong>t</strong>, you will be<br />
punished<br />
I really like <strong>to</strong><br />
<strong>rep<strong>or</strong>t</strong><br />
I donot really like<br />
<strong>to</strong> <strong>rep<strong>or</strong>t</strong><br />
Withi n the pers son<br />
Intern nal<br />
Negative motivational methods
What is<br />
motivation of<br />
<strong>healthcare</strong><br />
<strong>w<strong>or</strong>kers</strong>?
Job satisfaction<br />
White-collar <strong>w<strong>or</strong>kers</strong><br />
1. interesting w<strong>or</strong>k<br />
2. opp<strong>or</strong>tunity <strong>to</strong> develop special<br />
abilities<br />
3. enough inf<strong>or</strong>mation<br />
4. enough auth<strong>or</strong>ity<br />
5. enough help and<br />
equipment;<br />
6. friendly and helpful l co<strong>w<strong>or</strong>kers</strong><br />
7. opp<strong>or</strong>tunity <strong>to</strong> see results<br />
of w<strong>or</strong>k<br />
8. competent supervision<br />
9. responsibilities clearly defined<br />
10. good pay<br />
Blue-collar <strong>w<strong>or</strong>kers</strong><br />
1. good pay<br />
2. enough help and equipment<br />
3. job security<br />
4. enough inf<strong>or</strong>mation<br />
5. interesting esting w<strong>or</strong>k<br />
6. friendly and helpful<br />
co<strong>w<strong>or</strong>kers</strong><br />
7. responsibilities clearly<br />
l<br />
defined<br />
8. opp<strong>or</strong>tunity <strong>to</strong> see results of<br />
w<strong>or</strong>k<br />
9. enough auth<strong>or</strong>ity<br />
10. competent supervision<br />
Sanzotta , 1977
5 steps <strong>to</strong> change doc<strong>to</strong>rs’<br />
behaviours<br />
1. Investigation w<strong>or</strong>king‘s environment<br />
2. Understand current behaviours<br />
3. Choose behaviours required <strong>to</strong> be<br />
changed<br />
4. Conduct strategies <strong>to</strong> change<br />
5. Enhancing supp<strong>or</strong>t<br />
Cook 2004
5 strategies <strong>to</strong> change doc<strong>to</strong>rs’<br />
behaviours<br />
1. Supply detailed knowledge<br />
2. Surveillance and feedback<br />
3. Leadership<br />
4. Reminder system<br />
5. Supply documents<br />
Cook 2004
Conditions needed f<strong>or</strong> behavi<strong>or</strong> changes<br />
Products &<br />
Tools<br />
-Facilities<br />
-System<br />
Promotion<br />
-Training<br />
-Mass media<br />
-Activities & events<br />
Supp<strong>or</strong>tive<br />
Environment<br />
-Leader supp<strong>or</strong>t<br />
-Financing
Increasing the likelihood of<br />
behaviour change<br />
Products &<br />
Tools<br />
Promotion<br />
Increased<br />
likelihood of<br />
behavi<strong>or</strong><br />
change<br />
Supp<strong>or</strong>tive<br />
Environment<br />
When all the<br />
conditions are in<br />
place in the same<br />
place at the same<br />
time, it increases<br />
the likelihood of<br />
adopting and<br />
maintaining a<br />
practice.<br />
26
Conditions needed f<strong>or</strong> engaging<br />
<strong>healthcare</strong> <strong>w<strong>or</strong>kers</strong> <strong>to</strong> <strong>rep<strong>or</strong>t</strong> <strong>incident</strong>s<br />
Training<br />
Mass media<br />
What are <strong>incident</strong>s?<br />
<strong>How</strong> imp<strong>or</strong>tant?<br />
<strong>How</strong> <strong>to</strong> <strong>rep<strong>or</strong>t</strong>?<br />
-Poster<br />
-Pamphlet<br />
-Intranet<br />
Tools<br />
Good <strong>rep<strong>or</strong>t</strong>ing<br />
system<br />
Easy and simple<br />
Supp<strong>or</strong>tive<br />
environment<br />
Leader supp<strong>or</strong>t<br />
Bonus f<strong>or</strong> <strong>rep<strong>or</strong>t</strong>ing<br />
Feedback given <strong>to</strong> <strong>rep<strong>or</strong>t</strong>er<br />
27
Conditions needed f<strong>or</strong> engaging<br />
<strong>healthcare</strong> <strong>w<strong>or</strong>kers</strong> <strong>to</strong> <strong>rep<strong>or</strong>t</strong> <strong>incident</strong>s<br />
Training<br />
Mass media<br />
What are <strong>incident</strong>s?<br />
<strong>How</strong> imp<strong>or</strong>tant?<br />
<strong>How</strong> <strong>to</strong> <strong>rep<strong>or</strong>t</strong>?<br />
-Poster<br />
-Pamphlet<br />
-Intranet<br />
Tools<br />
Good <strong>rep<strong>or</strong>t</strong>ing<br />
system<br />
Easy and simple<br />
Supp<strong>or</strong>tive<br />
environment<br />
Leader supp<strong>or</strong>t<br />
Bonus f<strong>or</strong> <strong>rep<strong>or</strong>t</strong>ing<br />
Feedback given <strong>to</strong> <strong>rep<strong>or</strong>t</strong>er<br />
28
Training<br />
• Should be continuing education<br />
• Can be a part of patient safety course<br />
• Evidences showed that training can have<br />
immediate and long-term positive effects on<br />
knowledge, attitudes, skills and practices in<br />
<strong>incident</strong> <strong>rep<strong>or</strong>t</strong>ing<br />
Jansma JD. BMC Health Serv Res, 2011 Dec 12;11:335.
Training<br />
• Imp<strong>or</strong>tance of <strong>rep<strong>or</strong>t</strong> <strong>incident</strong>s<br />
• Purposes and aims of <strong>incident</strong> <strong>rep<strong>or</strong>t</strong>ing<br />
• Clarifying what <strong>to</strong> <strong>rep<strong>or</strong>t</strong>: clear definition<br />
of <strong>rep<strong>or</strong>t</strong>able <strong>incident</strong>s<br />
• Clarifying how <strong>to</strong> <strong>rep<strong>or</strong>t</strong><br />
• Designating specific members of staff<br />
with responsibility f<strong>or</strong> <strong>rep<strong>or</strong>t</strong>ing.<br />
• Making exciting <strong>to</strong> <strong>rep<strong>or</strong>t</strong>
Levels of <strong>incident</strong>s<br />
Level Content<br />
Example<br />
1 Err<strong>or</strong>s occur but are not<br />
Prepared wrong medicine<br />
done in patients<br />
but recognized bef<strong>or</strong>e<br />
giving g it <strong>to</strong> patient<br />
2 Err<strong>or</strong>s occur, are done in<br />
patients, but caused<br />
min<strong>or</strong> effects<br />
Withdraw blood f<strong>or</strong> wrong<br />
patient but recognized<br />
bef<strong>or</strong>e sending <strong>to</strong> the lab:<br />
blood taken repeatly<br />
3 Err<strong>or</strong>s occur, are done in<br />
Leave gauze, instruments<br />
patients, caused<br />
moderate effects<br />
in patients but discovered<br />
bef<strong>or</strong>e patients leave<br />
operating room
Levels of <strong>incident</strong>s<br />
Level Content<br />
Example<br />
4 Err<strong>or</strong>s occur and caused Operated wrong patient,<br />
severe effects<br />
<strong>or</strong> wrong site; causing<br />
injures f<strong>or</strong> patients<br />
5 Err<strong>or</strong>s occur and caused<br />
death<br />
Used wrong dose <strong>or</strong><br />
drugs, wrong blood<br />
group; causing patients<br />
‘death
Rep<strong>or</strong>ting System<br />
• the process needs <strong>to</strong> be simplified<br />
– clear definitions f<strong>or</strong> classifications<br />
– structured framew<strong>or</strong>k f<strong>or</strong> contribu<strong>to</strong>ry<br />
fac<strong>to</strong>rs<br />
• designated staff <strong>to</strong> rec<strong>or</strong>d <strong>incident</strong>s<br />
• providing the possibility <strong>to</strong> <strong>rep<strong>or</strong>t</strong><br />
anonymously<br />
• providing feedback
Rep<strong>or</strong>ting System<br />
• A Web-based based electronic <strong>rep<strong>or</strong>t</strong>ing system can be<br />
helpful<br />
- <strong>rep<strong>or</strong>t</strong> <strong>incident</strong> events anonymously and<br />
confidentially<br />
- allows <strong>incident</strong>s <strong>to</strong> be updated on the<br />
database locally<br />
• The studies showed a significant improvement in<br />
<strong>incident</strong> <strong>rep<strong>or</strong>t</strong>ing rates after the introduction of<br />
the new electronic <strong>rep<strong>or</strong>t</strong>ing system.<br />
Parmelli E Cochrane Database Syst Rev 2012 Aug 15;8:CD005609<br />
Parmelli .E, Cochrane Database Syst Rev. 2012 Aug 15;8:CD005609.<br />
Kuo YH. Comput Inf<strong>or</strong>m Nurs. 2012 Jul;30(7):386-94.
Supp<strong>or</strong>tive environment<br />
• Creating an <strong>incident</strong> <strong>rep<strong>or</strong>t</strong>ing culture<br />
• Feedback given <strong>to</strong> <strong>rep<strong>or</strong>t</strong>ers<br />
• Feedback and reassurance <strong>to</strong> staff about<br />
the nature and purpose of systems.<br />
• Leadership supp<strong>or</strong>t<br />
– Bonus f<strong>or</strong> good <strong>rep<strong>or</strong>t</strong>er
Western and Asian culture<br />
http://www.vincentchow.net/2004/western-asian-culture-comparison
Method <strong>to</strong> ensure maintaining compliance
National Rep<strong>or</strong>ting and Learning System (NRLS) Quarterly<br />
Data W<strong>or</strong>kbook up <strong>to</strong> December 2011
Engage <strong>healthcare</strong> w<strong>or</strong>ker <strong>to</strong> <strong>rep<strong>or</strong>t</strong> <strong>incident</strong>s…
Thank you
September 13 & 14, 2012 2 ● MeliaHotel l ● Hanoi, Vietnam<br />
Assoc. Prof. Le Thi Anh Thu<br />
Chief of Risk Management Unit, Cho Ray Hospital<br />
letathu@yahoo.com
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