How to engage healthcare workers to report incidents or medical errors? ? A/Proff LLe Thi Anh A/P A h Thu, Th MD PhD Chief of Risk Management Unit Cho Ray Hospital, HCMC, Vietnam Engage healthcare worker to report incidents… Reporting incidents or medical errors: an important task Learning from errors to prevent harm Serious injuries or death 1 Minor injuries 29 Near misses/ Latent factors 300 Heinrich pyramid Reporting incidents or medical errors: an important task Learning from errors to prevent harm Serious injuries or death 1 Minor injuries 29 Near misses/ Latent factors 300 Heinrich pyramid Voluntary reporting incidents or medical errors is required Incidents can occur in at least 3% of all patients patients Require healthcare worker to report incidents voluntary Voluntary incident reporting system plays a key role in risk i k managementt and d improving i i patient ti t safety f t Panzica M et al , Unfallchirurg 2011 Sep;114(9):758-67. Vincent et al. NHS of England and Wales 2001 Challenges • Low number of incident reporting: Hospital staff did not report 86 % of events • Voluntary incident reporting yielded a much lower reporting rate of adverse drug events reported in the literature. Barriers ‘Culture of blame’ • Guilt G ilt or meting ti outt punishment i h t • Feared legal g repercussions p • Fear of disciplinary action Sue M Evans, Evans, Qual Saf Health Care 2007 Neuspiel DR, Agency for Healthcare Research and Q lit 2008 Aug. Quality; A Barriers • Errors are an ‘inevitable’ and ppotentiallyy unmanageable feature • Time constraints • Incident reporting is ‘pointless ’ • Lack L k off feedback f db k • Did not know what or how to report p Sue M Evans Evans,, Qual Saf Health Care 2007 Neuspiel DR, Agency for Healthcare Research and Quality; 2008 Aug. Barriers Nurses tend to report more frequently than doctors Evans SM et al; Qual Saf Health Care , 2006 Feb;15(1):39-43. Barriers Western and Asian culture http://www.vincentchow.net/2004/western-asian-culture-comparison Barriers Western and Asian culture http://www.vincentchow.net/2004/western-asian-culture-comparison An example In an outpatient department, Nurse A called: Ms An An, please come in in” “Ms A woman said “Yes”, stood up and was told to enter into examination room. room Doctor informed her that she is pregnant and say congratulation The woman is very surprised and congratulation. said “it is impossible, doctor!” “Are Are you Le An?” An? “No No I’m I m not, I am Nguyen An” An Nurse A shouted at her “Oh dear, I did not call you, why did you enter the room!” room! • Do you think the nurse will report this situation as an incident? • The reason why Nurse A does not report this incident ? • How to persuade staff to report such incidents? How to engage healthcare worker to report incidents voluntary? y Multi--approach Multi O direction One di ti Behaviour change Motivation is the art of getting people to do what yyou want them to do because they want to do it Dwight D. Eisenhower 1953-61 Reportt and R d you will get bonus I really like to report If you do not report, you will be punished I donot really like to report Negative motivational methods Intern nal Some eone else e motivate es you  Within the pers son Exterrnal Positive motivational method What is motivation of healthcare workers? Job satisfaction White-collar workers Blue-collar workers 1. interesting work 2 opportunity to develop special 2. abilities 3. enough information 4 enough 4. eno gh authority a tho it 5. enough help and equipment; 6 friendly 6. f i dl and d helpful h l f l coworkers k 7. opportunity to see results of work 8. competent supervision 9. responsibilities clearly defined 10. good pay 1. good pay 2 enough help and equipment 2. 3. job security 4. enough information 5 interesting 5. inte esting work ok 6. friendly and helpful coworkers 7 responsibilities 7. ibiliti clearly l l defined 8. opportunity to see results of workk 9. enough authority 10. competent supervision Sanzotta , 1977 5 steps to change doctors’ behaviours 1 Investigation working‘s environment 1. 2 Understand current behaviours 2. 3. Choose behaviours required to be changed 4. Conduct strategies to change 5. Enhancing support 5. Cook 2004 5 strategies g to change g doctors’ behaviours 1. Supply detailed knowledge 2. Surveillance and feedback 3. Leadership 3. 4 Reminder system 4. 5. Supply documents Cook 2004 Conditions needed for behavior changes Products & Tools Promotion -Facilities Facilities Mass media -Mass -System -Activities & events -Training Supportive Environment -Leader support -Financing Financing Increasing the likelihood of behaviour change Products & Tools P Promotion ti Increased likelihood of behavior change h Supportive Environment When all the conditions are in place in the same place at the same time it increases time, the likelihood of adopting and maintaining a practice. i 26 Conditions needed for engaging healthcare workers to report incidents Training M Mass media di What are incidents? -Poster How important? -Pamphlet P hl How to report? -Intranet Tools Good reporting system Easy and simple Supportive environment Leader support Bonus for reporting p g Feedback given to reporter 27 Conditions needed for engaging healthcare workers to report incidents Training M Mass media di What are incidents? -Poster How important? -Pamphlet P hl How to report? -Intranet Tools Good reporting system Easy and simple Supportive environment Leader support Bonus for reporting p g Feedback given to reporter 28 Training • Should be continuing education • Can be a part of patient safety course • Evidences showed that training can have immediate and longlong-term positive effects on knowledge, attitudes, skills and practices in incident reporting Jansma JD. JD BMC Health Serv Res, Res 2011 Dec 12;11:335. 12;11:335 Training • Importance of report incidents • Purposes and aims of incident reporting • Clarifying y g what to report: p clear definition of reportable incidents • Clarifying how to report • Designating specific members of staff with responsibility for reporting reporting. • Making exciting to report Levels of incidents Level Content Example 1 Errors occur but are not done in patients Prepared wrong medicine but recognized before giving g g it to p patient 2 Errors occur, are done in patients, but caused minor i effects ff 3 Errors occur occur, are done in patients, caused moderate effects Withdraw blood for wrong patient but recognized b f before sending di to the h llab: b blood taken repeatly Leave gauze gauze, instruments in patients but discovered before patients leave operating ti room Levels of incidents Level Content Example 4 Errors occur and caused Operated wrong patient, severe effects or wrong site; causing injures for patients 5 Errors occur and caused Used wrong dose or death drugs, wrong blood group; causing patients ‘death Reporting System • the process needs to be simplified – clear definitions for classifications – structured framework for contributory factors • designated staff to record incidents • providing the possibility to report anonymously l • providing feedback Reporting System • A WebWeb-based electronic reporting system can be helpful - report incident events anonymously and confidentially - allows incidents to be updated on the database locally • The studies showed a significant improvement in incident reporting rates after the introduction of the new electronic reporting system. Parmelli .E, E Cochrane Database Syst Rev. Rev 2012 Aug 15;8:CD005609. 15;8:CD005609 Kuo YH. Comput Inform Nurs. 2012 Jul;30(7):386-94. Supportive environment • Creating an incident reporting culture • Feedback given to reporters • Feedback and reassurance to staff about the nature and purpose of systems systems. • Leadership support – Bonus B ffor good d reporter t Western and Asian culture http://www.vincentchow.net/2004/western-asian-culture-comparison Method to ensure maintaining compliance National Reporting and Learning System (NRLS) Quarterly Data Workbook up to December 2011 Engage healthcare worker to report incidents… Thank you y S September 13 & 14, 2012 ● b 3& 20 2 Melia li Hotel ● l Hanoi, Vietnam i i Assoc. Prof. Le Thi Anh Thu Chief of Risk Management Unit, Cho Ray Hospital [email protected]