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Overcome 3 Challenges in Hospital Incident Reporting

Analysis  |  By Christopher Cheney  
   May 31, 2018

"Many organizations call these documents incident reports. We call them safety reports, which takes away a pejorative and negative connotation. The whole initiative was called 10,000 Good Catches and when people make good catches, we celebrate them," Shah says.

Other efforts to gain trust and reporting participation from Children's National staff have included one-on-one outreach, naming a monthly Reducing Harm Hero, and the awarding of "Zero in on Zero Harm" pins.

Staff members also know their incident reports are being reviewed at a senior executive level, Shah says. "I read every incident report in the organization. I made that pledge about three-and-a-half years ago, when we had 4,000 incident reports. I still stand by that pledge when we have 11,000 incident reports."

One of Shah's subordinates also reads all incident reports, as does the chief risk officer and a deputy. "Everyone in the organization knows that when they file an incident report, at least four leaders will look at it," he says.

  1. Show reporting makes a difference

Showing employees that their incident reports make a difference also can be challenging. But Shah cites two examples of incident reports that led to significant quality or safety improvements.

Example 1: Code Simulation Program

In one instance, a patient required resuscitation at a Children's National satellite clinic. "That is pretty much all the incident report said," Shah says.

Based mainly on the incident report, Children's National decided to spread its emergency code simulation program from the main hospital to the satellite clinics. The simulation program focuses on cardiac arrest and other resuscitation emergencies. Children's National subject-matter experts developed the program, which is also staffed internally.

Shah believes the new code training has saved at least one life.

"Six months later, a child was having a seizure in one of our satellite clinics, turned blue, and needed resuscitation. It took EMS about 10 minutes to get to the clinic. By the time EMS arrived, the child was intubated, stabilized, and properly coded."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


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