AUG/SEPT 2002
Volume 26 • No. 8

Online incident-reporting system will allow hospital to respond more quickly, identify trends

Stanford Hospital is preparing to roll out a new online incident-reporting system that has several advantages over the current paper-based system. The advantages include fewer delays; transmission to several departments simultaneously; and a data-analysis mechanism that will help the hospital identify broad patterns of error. Physicians are being encouraged to use the system to report any incidents they are aware of.

Called Patient Safety Net, the online incident-reporting tool is being tested on five units at Stanford Hospital, which is one of just six academic medical centers in the country involved in beta-testing the program. Plans call for the system to be implemented hospital-wide by November after feedback is gathered and refinements made. Patient Safety Net was developed by the University HealthSystem Consortium, a coalition of 87 academic medical centers including Stanford.

Brenda Fischer, director of quality improvement, said the implementation of Patient Safety Net is a significant step forward in the hospital's patient safety efforts because it will facilitate a more proactive approach to medical errors and other unanticipated incidents. "We've been in a reactive mode, where we react to problems as they arise," she said. "We want to get into a proactive mode, where we figure out where the problems are and take steps to prevent them from recurring."

Patient Safety Net is more sophisticated than the current incident-reporting form in several ways. For example, it asks the user to identify the type of incident by selecting from a menu of options, including medication errors, patient falls and surgical complications. Based on the description selected, the user is presented with a set of questions that apply specifically to that type of incident. Many of the questions prompt the user to select responses from a list, while others are open-ended, leaving room for a narrative.

Once an incident report is completed, it is automatically sent to the nurse manager of the unit where the incident occurred, as well as other departments that have been preprogrammed to receive certain types of incident reports. For example, all reports regarding medication errors are automatically sent to pharmacy and to risk management.

This real-time, simultaneous transmission enables hospital personnel to respond to incidents more promptly and work together in a more coordinated fashion, explained Joan Caldwell, nurse manager for medical/surgical unit F3, one of the five units that began testing the system in mid-May. "It significantly improves the timeliness of reporting. It allows you to follow up much more quickly," she said. Caldwell noted that the online form is easy to fill out and that the task takes just a couple of minutes.

One of Patient Safety Net's greatest benefits is that it will enable hospitals to identify and address broad trends in errors. Each month, the incident reports will be submitted to a database at University HealthSystem Consortium, and a data-analysis expert there will generate a report indicating any significant trends. Such analysis could highlight a hospital that is having problems administering a certain type of medication on several units. That would enable hospital personnel to examine the factors at work and make changes to prevent the problem from recurring - such as beefing up training for nurses who administer the medication, or re-evaluating the equipment used to administer it.

The ultimate goal, Fischer said, is to get to the root of problems and improve hospital processes so errors will be less likely. "We need good, real-time information so we can get in there, strategize on what the issues are, and find ways to make things better."

Another improvement expected to come with Patient Safety Net is greater accountability. Previously, no one person at the hospital has been responsible for reviewing and addressing all incident reports. In early August, however, the quality improvement department hired Debra Gerardi as the hospital's patient safety program manager (see story), a newly created position that includes oversight of incident reports.

While most incident reports are filled out by nurses, Fischer said she hopes the convenience and benefits of the online system will encourage more physicians to fill them out. Once Patient Safety Net is implemented throughout the hospital, it will be available on the desktop of nearly all workstations on the patient units.

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