Updated: Feb 27
Authors: Alex Chan, Laura Pozzobon
You are a physician caring for a 4-year-old patient in the Emergency Department (ED) presenting with a fever. Before ordering Acetaminophen for the patient, you check the patient’s weight on the emergency record, which you read as 17kg. You then write an order based on this weight. The ED nurse checks the order to see if the medication dose is safe using the hospital medication formulary. After that, the nurse approaches you and states they are concerned that the dose is too high based on the formulary. You both cross-check the weight-based dose calculation and realize that you misread the weight hand written on the emergency record. You initially read the weight as 17kg and the nurse read 12kg. After confirming with a scale, you determine the patient’s true weight is 12kg. You recognize that misreading a paediatric patient’s weight can result in significant patient harm when administering medications. You also want to make system level changes to prevent this from occurring.
The Importance of Patient Safety Reporting Systems
Patient safety event (PSE) reporting systems allow healthcare workers (nurses, physicians, pharmacists, clerks etc.) to report PSEs, near misses, and/or potentially unsafe conditions in healthcare, and are also pillars of patient safety and quality improvement.(1) This is especially important for the ED where as many as 8.5% of patients experience PSEs – the majority of which are preventable. Many of these PSEs can be attributed to the unique characteristics of the department, such as its triage system, fast paced environment rich with distractions and complex patients, high patient turnover, and vulnerability to overcrowding.(2–5)
A previous post discussed the “Swiss Cheese Model” proposed by James Reason, which explains how weaknesses (or “latent safety threats”) in a system can lead to active PSEs.(6) Within complex systems, such as the ED, there are multiple levels of defence to prevent safety events from reaching patients which may have inherent weaknesses. PSE reports for all levels of harm (e.g. no harm to severe harm) can help organizations identify these weaknesses and common PSE contributing factors, as well as guide the development of tailored strategies to mitigate those factors. Figure 1 applies the Swiss Cheese Model to our near miss medication administration case.(6)
Elements of an Effective ED PSE Reporting System
Patient safety hazard detection strategies in the ED fall under the category of either passive or active forms of surveillance.(7)
Passive voluntary reporting, the focus of this post, rely on the individuals involved to report near misses or PSEs.
Active forms of surveillance may include:
Return visit quality programs
Direct observation of providers
Manual or automated chart reviews
For PSE reporting to be meaningful, events need to be reported and systems need to be in place for timely event analysis. Additionally, feedback needs to be provided to staff involved to further facilitate reporting, and visible changes need to be implemented to address PSE contributing factors.(3)
Barriers and Limitations to PSE Reporting
Although the benefits of an effective PSE reporting system are clear, there exist many barriers that can prevent their appropriate implementation and/or usage. In prior literature, it was estimated that only 4-50% of PSEs are reported.(3) Additionally, researchers in a prior study involving 1600 hospitals in the US found that only 13% of hospitals have broad staff involvement in adverse event reporting. Overall, reasons for low reporting can be categorized into two main categories: Systematic and Provider.(8)
Lack of structured mechanisms to review reports in a timely and effective manner.
Absence of a supportive culture to facilitate and promote reporting.
The non-stop nature of the ED, and lack of continuity of care, inherent in the specialty, exacerbates these issues.
Failure to provide feedback to report initiators (most reported factor).
Lack of education regarding how to report events.
Combination of heavy workloads and viewing PSEs as trivial.
Cumbersome or unintuitive reporting system forms.
Worry of a lack of anonymity and fear of repercussions following reporting.
Strategies to Improve PSE Reporting in EDs
There is an abundance of literature identifying strategies to improve PSE reporting systems, for instance:
Fostering a Just Culture: CMPA identified a “just culture of safety” to be pivotal in fostering effective PSE reporting, which involves all leaders and staff being committed to the safest possible care of patients to patients amongst all else. As covered in a former post, such a culture approaches patient care in a systems-based approach that prioritizes learning from PSEs rather than imparting blame or punishment.(12)
Closing the Loop with Report Initiators: Initiatives that encourage staff to report PSEs (e.g. positive recognition), as well as provide feedback to report initiators regarding the outcome of their report review.(13)
Switching to an Electronic Reporting System: E-reporting takes advantage of technological advancements. It has also increased rates of reporting in EDs by mitigating the bothersome nature of PSE reporting and improving ease of access.(14,15)
Educating ED Medical Students/Residents/Fellows: Despite delivering direct care to patients, student and resident participation has historically been disproportionately low. Also, implementation of educational initiatives on PSEs and their reporting can significantly increase resident reporting.(16)
Now that you know more about what PSE reporting systems are and the role they can play in improving our systems, you decide to log-in to your hospital’s PSE reporting system and complete a report for this near miss safety event. The ED department head then follows-up with you to learn more about the event. They also share that they will be taking this safety event to the ED’s safe medication administration committee as it highlights a weakness within the paediatric medication administration practices in this ED.
Senior Editor: Ahmed Taher
Copyedited by: Laura Pozzobon
Pronovost P, Morlock L, Sexton B, et al. Improving the Value of Patient Safety Reporting Systems. In: Advances in Patient Safety: New Directions and Alternative Approaches . Vol 1. Agency for Healthcare Research and Quality; 2008:1-9. Agency for Healthcare Research and Quality
Bigham E, Bull M, Morrison M, et al. Patient safety in emergency medical services: executive summary and recommendations from the Niagara Summit. CJEM. 2011;13(1):13-18. doi:10.2310/8000.2011.100232.
Jepson Z, Darling C, Kotkowski K, et al. Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process. BMC Emerg Med. 2014;14(20). doi:10.1186/1471-227X-14-20
Brubacher J, Hunte G, Hamilton L, Annemarie T. Barriers to and incentives for safety event reporting in emergency departments. Healthc Q. 2011;14(3):57-65. doi:10.12927/hcq.2011.22491
Burbacher J, Hunte G, Hamilton L, Taylor A. Barriers and Incentives for Safety Event Reporting in Emergency Departments. Healthcare Quarterly. 2011;14(3). https://pubmed.ncbi.nlm.nih.gov/21841378/
Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770/.
PSNet. Reporting Patient Safety Events. Patient Safety Primer. Published 2019. https://psnet.ahrq.gov/primer/reporting-patient-safety-events
Farley D, Haviland A, Jain A, Battles J, Munier W, Loeb J. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care. 2008;17(6):416-423. doi:10.1136/qshc.2007.024638
Evans S, Berry J, Smith B, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf health Care. 2006;15(1):39-43. doi:10.1136/qshc.2004.012559
Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract. 1999;5(1):13-21. https://pubmed.ncbi.nlm.nih.gov/10468380/
Uribe C, Schweikhart S, Pathk D, Dow M, Marsh G. Perceived barriers to medical-error reporting: an exploratory investigation. J Healthc Manag. 2002;47(4):263-279. https://pubmed.ncbi.nlm.nih.gov/12221747/
CMPA. Just culture of safety: How to report and participate in reviews of patient safety incidents. CMPA Safety of care: Improving Patient Safety and reducing risks. https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2010/just-culture-of-safety-how-to-report-and-participate-in-reviews-of-adverse-events.
No authors listed. Developing a reporting culture: Learning from close calls and hazardous conditions. Sentinel event alert. 2018;60:1-8.
Okafor N, Doshi P, Miller S, et al. Voluntary Medical Incident Reporting Tool to Improve Physician Reporting of Medical Errors in an Emergency Department. West J Emerg Med. 2015;16(7):1073-1078. doi:10.5811/westjem.2015.8.27390
Schultz T, Crock C, Hansen K, Deakin A, Gosbell A. Piloting an online incident reporting system in Australasian emergency medicine. Emerg Med Australas. 2014;26(5):461-467. doi:10.1111/1742-6723.12271. Epub 2014 Aug 5
Stewart D, Junn J, Adams M, et al. House Staff Participation in Patient Safety Reporting: Identification of Predominant Barriers and Implementation of a Pilot Program. South Med J. 2016;109(7):395-400. doi:10.14423/SMJ.0000000000000486