Questions and Answers: Patient Safety is Based on Data-Driven Leadership

Patient safety challenges are compounded by healthcare workforce challenges. However, a workplace culture focused on measuring what goes wrong and implementing changes to address root causes—driven by reporting and analytics technology and encouraged by executive example—can address these significant forces impacting healthcare delivery.

As health care workers signaled plans to leave the sector after the exhaustion of the COVID-19 pandemic years, the nonprofit Emergency Care Research Institute said in 2022 that it was concerned about a widespread increase in patient safety risks.

More recently, ECRI, in its latest report, identified errors in medication administration, delays in care due to shortages of medications and supplies, workplace violence and patient falls as the top safety problems in healthcare. annual list of hazards to patient safety.

But by implementing data and analytics tools for patient safety and performance improvement, healthcare organizations can use “near miss” data to prevent incidents that lead to injuries – and reduce costs, too.

Today’s healthcare environment demands effective digital tools and a commitment to cultural change, according to Heidi Raines, founder and CEO of Performance Health Partners, a provider of healthcare safety software.

“Rapid action is essential in healthcare, where early intervention can have a major impact on outcomes,” she says.

We spoke with Raines about near-miss reporting and how better analytics and a culture of data-driven leadership can improve patient safety.

Q. What is confusing about the near miss reporting process and how can it be improved?

A. According to Heinrich’s Law, for every safety incident involving injury, 300 near misses are often underreported or underreported. This highlights a critical opportunity to prevent injury and damage incidents within healthcare facilities.

A near miss, or what we in healthcare call a “good catch,” is an incident in which someone was nearly injured or harmed, but it did not happen because of timely intervention or chance.

The first step in refining the near-miss reporting process is for the organization to clarify what exactly constitutes a near-miss. This clarity is critical to eliminating the confusion that healthcare professionals often experience in determining what and when to report observations. By defining and effectively communicating the details of what should be reported—including clear examples and categories of near-misses—we can ensure that professionals understand the importance of reporting, the mechanisms for accurate reporting, and the role they play in prevention.

In addition, leadership must remove the fear of repercussions from employees.

Leadership is responsible for creating a transparent and supportive environment where employees feel safe to report near misses without fear of blame. This approach promotes a learning culture by focusing on systemic improvements rather than just the human factors.

Q. How can healthcare providers save time when reporting near misses?

A. Technology significantly improves the near miss reporting process by providing healthcare workers with easily accessible tools, allowing them to quickly report observations and maintain their primary focus on patient care. A reporting tool can be seamlessly integrated into daily workflows by adding shortcuts to all terminals and devices, or by placing QR codes strategically throughout the facility for easy access. This intuitive system ensures it is readily available for use.

We have dramatically reduced the time it takes to complete and submit a report – from typically over 20 minutes using conventional methods, to less than two minutes. This dramatic reduction reduces paperwork and frees up valuable time for healthcare providers to focus more on patient care.

The risk team receives real-time alerts about the potential risk, allowing them to eliminate a potential root cause before damage occurs. Such systems enhance the healthcare environment with their instant notifications, alerting leaders to issues immediately and ensuring rapid responses.

When a behavioral health client implemented near-miss reporting, the provider experienced a significant improvement, reducing the time to address and resolve issues by 75%—from 20 days to five days. Such rapid response is critical to ensuring patient safety.

Q. How can healthcare providers best use near-miss reports to track trends across services and locations?

A. Near-miss reports track trends and identify safety issues across services and locations in healthcare facilities. Providers are effectively leveraging this data using advanced tools such as root cause analysis, data visualization, and trend benchmarking. These technologies transform complex data sets into clear, actionable insights, enabling proactive responses to safety issues.

Many healthcare providers need help effectively analyzing large amounts of incident data.

Without data analytics technology and automation, identifying trends in incident reports was time-consuming, often resulting in incomplete analyses. However, with the implementation of advanced analytics tools and benchmarking automation, this data can now fully contribute to performance improvements and facilitate the implementation of real preventive measures.

To illustrate the impact of these tools, consider the experience of one of our client hospitals, which initially struggled to identify the root cause of medication errors. After integrating a patient safety and incident reporting system into their processes, they identified the root cause in the pharmacy. Powered by data aggregation and analytics, this group tackled the problem head-on and achieved a remarkable 51% reduction in medication errors within three months.

Q. How does incident reporting improve employee engagement and organizational culture?

A. An astonishing 89% of our clients report improved satisfaction with employee performance after implementing reporting systems. Additionally, 74% have seen significant improvements in targeted safety areas within 90 days of using our services. This data highlights the profound impact that efficient incident reporting has on overall workplace satisfaction and safety outcomes.

By increasing employee involvement in incident reporting, organizations can move from a reactive to a proactive approach to healthcare safety management.

This proactive engagement significantly changes organizational culture by moving away from simply reacting to incidents. Instead, it encourages preventative identification and resolution of potential safety issues, and embeds a culture where safety is a shared responsibility at all levels of the organization. This shift is essential for maintaining a continuous and robust safety culture, and ensures that every team member feels empowered to contribute to safer healthcare environments.

Achieving such a transformation requires strong leadership. Nearly all of our clients emphasize the critical role of executive buy-in. Leaders must not only support these initiatives, but also actively promote and sometimes encourage incident reporting.

Q. Speaking of leadership, why does it play such a big role in improving patient safety?

A. Leaders must create safe channels for reporting misconduct.

Implementing confidential and even anonymous reporting systems can dramatically change how safety issues are reported. These systems ensure staff can raise concerns without fear of jeopardizing their jobs or reputations.

Research published in the Journal of Hospital Medicine indicates that having an anonymous reporting system can increase the reporting of medical errors by 54% and near misses by up to three times compared to non-anonymous systems. Workplace misconduct studies further support this idea, revealing that 70% of employees are more likely to file reports when their anonymity is protected.

Patient safety transformation fundamentally starts at the top, with leadership being the cornerstone of any successful healthcare safety initiative.

Effective leaders catalyze change by embodying the principles of transparency and accountability. By openly discussing incidents and the lessons learned, rather than assigning blame, they not only build trust but also underscore a deep organizational commitment to continuous improvement.

This approach sets a powerful precedent and demonstrates a focus on improving outcomes and creating a supportive environment. This builds trust and motivates the entire organization to strive for a higher standard of patient care.

Finally, the role of feedback loops cannot be overstated. When management actively responds to reports and communicates the actions taken, it reinforces the value of speaking up. It shows everyone that their voice matters and their contributions lead to safer care environments.

Furthermore, these feedback loops are vital for facilitating incremental change. By systematically addressing and learning from each report, small adjustments accumulate over time, leading to significant improvements in patient safety and organizational culture.

Andrea Fox is Editor-in-Chief of Healthcare IT News.
Email address: afox@himss.org
Healthcare IT News is a publication of HIMSS Media.