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Under-reporting Patient Safety Incidents: A Real Problem

Rohini K

Amy had been a staff nurse in the same hospital for 30 years. Her shift starts with making rounds in different 15 wards and ensuring they follow all the patient safety protocols.

One day she found water on the Ward No. 3 floor due to the cleaning staff’s negligence. Despite noticing this issue, she keeps on moving with her job. Her reasons to not report the problem were:

  • – Reporting meant lots of paperwork
  • – Reporting could put her hours behind schedule
  • – She had to waste time on hearing back from the admin department
  • – Importantly, she doesn’t want to cause any trouble to the poor cleaning staff

So, she didn’t report at that time, and the issue remained unresolved. After a few days, some patients fall from the wet floor in the ward. Now patient falls are serious. And it doesn’t look good if the investigation reveals negligence. So, they go unreported as well!

The result? The hospital continues to score poor safety results. The reason for not reporting could be credible or just laziness. Under-reporting doesn’t help the organization meet its safety goals. The story above is not an isolated story of anyone hospital or nurse. Statistics tell us that this seems to be the norm:

  • – Almost 25% of incidents go unreported. (Source: Sentis)
  • – Around 100 errors go unreported while recording. (Source: Pharmacy Times)
  • – Every year about 7,150 deaths occurred due to not reporting incidents in hospitals. (Source: Yale News)
  • – The Journal of Patient Safety]] suggested in 2013 that 440,000 people per year die from preventable medical errors. (Source: Medscape)

Even though we have data indicating under-reporting in hospitals, not many practitioners follow the proper reporting process. QUASR tries to address this issue with simple tools that seek to address common reasons for under-reporting. Let us first understand Under-reporting and its Reasons.

What is Under-reporting?

Under-reporting means an issue, incident, or the fact that an individual or organization has not reported. Under-reporting is a failure in data gathering.

In hospitals, sometimes individual staff hide or don’t report some incidents. However, unfortunately, it is not possible to know ahead of time how these under-reported incidents affect long-term patient safety.

Recently a study published in the Stanford Business on how hospitals acquired infections is reported in Medicare claims. Researchers found that hospitals with lighter reporting requirements were more miscoded by examining hundreds of Medicare patients, as hospital-acquired infections(HAIs) were presented on admission (POAs). 18.5% of infections said to present upon admission were acquired in the hospital.

Overall, under-reporting is a critical issue that should be analyzed and treated by the hospitals on priority.

4 Reasons Behind Under-reporting in Hospitals

There are plenty of different reasons that generate under-reporting problems in hospitals worldwide. Some of the common underreporting causes in hospitals are:

Fear of Repercussion

One of the most common reasons why an incident goes unreported is a fear of repercussion. We don’t think there are any organisations in today’s day and age where an employee is penalised for taking the initiative.

Still, many staff that we have met on and off have mentioned that they are afraid it will reflect poorly on them if they reported an issue. Organisations may have to do more to ensure that an incident is not a reflection of the staff. From our discussions with our clients, this is often amongst the top few reasons why incidents go unreported.

No Time To Report

Staff on the floor are amongst the busiest people we meet on a given day. Incident reporting in such a dynamic is quite tricky. Most incident forms are lengthy and require the staff to write up in sufficient detail, then participate in multiple investigation sessions to complete the incident report.

Often incident reports have to be filed within a predetermined number of hours since the incident occurred. If they cannot do this, they usually forget and don’t get around to filing the same. It is especially true for incidents that don’t cause any harm to the patients as such since everyone’s priority is patient safety and care.

Hospital staff often do not have time, and hence they may tend to ignore incidents that they believe are not serious enough. Lack of time is also one of the top reasons why under-reporting occurs, based on our discussions with our clients.

Lack of Transparency

Often the reporting person is wholly left out of the incident processing loop. Many organisations have a perfect reason to do this for some types of incidents too. But some processes are not designed to be transparent at all. The process leaves many people out, and they don’t understand how their reporting an incident helped the organisation or patient benefit. This can also lead the staff to believe that their incident report went into some “filing black hole”, and no one even had a chance to process their report.

It is possible to revise the incident process to be more transparent when it is digitalised. A digital system allows for frequent and early feedback to all the stakeholders. By being transparent, the system becomes more inclusive of all staff and helps them realise the value of their contribution.

Insufficient Training or Knowledge

Many healthcare institutions are unaware of the fact that their incident reporting system isn’t transparent. Not many hospital staff members know when, how and whom to report. The lack of reporting knowledge occurs due to poor communication.

Most hospitals would share this information with their new workers during the orientation and training process. But learning occurs differently to different people. Often, a single knowledge sharing session is insufficient to orient all the users in the processes.

Additionally, organisations share critical information via email. Frontline workers like nurses or ward attendants don’t have regular access to a computer to receive information on time.

The only way to address this is continuous training or frequent sessions to help the staff get oriented to new systems better. The other often ignored method is to build intuitive systems.

How does QUASR help you address under-reporting?

QUASR has a suite of nifty tools integrated into the system to help address under-reporting. For instance, to specifically address the fear of repercussions, QUASR uses a novel pseudo-anonymous reporting that allows users to hide their identity at the time of reporting. We do this so that the users will feel safe reporting, but at the same time, the Quality Managers don’t have to deal with insufficient data for investigation later on. Similarly, we use a multi-stage questionnaire for collecting the details with the ability to resume your data at any step. This allows staff to fill in the incident report over multiple breaks without blocking off a significant portion of their time to do this.

QUASR, at its core, believes that an incident management system is an essential knowledge repository for the healthcare organisation to learn from and disseminate information over. So transparency is one of the critical considerations of the design with suitable mechanisms to protect sensitive data when the need arises.

Finally, QUASR aims to keep the application simple in appearance and manner. The bottom line consideration for every element added into QUASR is the amount of training each user would need to use that element effectively. We have designed the UI in line with some of the social applications familiar to us. This allows us, the users, to quickly adopt and start using QUASR with minimal training efforts.

We will be covering some of these features like pseudo-anonymity or sensitive incidents in individual blog posts in the future. So do watch this blog for more information. Meanwhile, feel free to contact us or drop us a note if you need further information on any of these topics in particular or QUASR in general!

An Introduction to QUASR Basic

Abishek Goda

When we brainstormed the QUASR Lite design, we had a list of features for another version that’s slightly more advanced than Lite but not as involved as the Enterprise version. Even amidst our customers and prospects, we understand Lite is a little too simple for their process because they have had a computerised system in place for a while and are familiar with the advantages of having one. They need to upgrade but are not ready to set aside budgets or time for enterprise implementation. So we built QUASR Basic to give you a flavour for what the enterprise system can do for you without having to go through full implementation. There are limitations, of course. In this post, allow us to introduce QUASR Basic to you.

QUASR Basic is Lite with a workflow

QUASR Basic is Lite with a workflow. It does not have all Enterprise version features and will probably remain that way for more time. BASIC and Enterprise target different types of organisations. BASIC targets single/independent hospitals, which are:
1) accustomed to having a system in place.
2) using Lite for a while and want to graduate their process.
3) Enterprise-ready users who wish to try QUASR before taking on an enterprise implementation.

I hope we convinced you to read on, as this might be just what you need at your org right now.

What do we mean by a workflow anyway? In Lite, when you report an incident, the system doesn’t do much apart from saving it to a database and ensuring the data’s integrity. In BASIC, however, a few things happen: the system triggers an email to a pre-designated group of Quality Managers as soon as you report an incident. The incident details collected also contain additional information such as the Supervisor for the incident, a team of investigators, a group of people to sign off on the incident etc. Each of these is a stage in the incident lifecycle. The Supervisor assigned is then required to perform the review and fill in the SBAR. Similarly, upon quality review completion, the investigation report can be updated and so on. This linearising sequence of events in the incident lifecycle is what we call the “workflow”.

There’s more

But that’s not all of it either. There are more things under the hood in BASIC as compared to Lite. Flags assigned to incidents in Lite are merely indicators. They help you identify or classify incidents at a glance. However, in BASIC, you can use Flags to include pre-designated people in the incident loop. They’d automatically get notifications and access to the incident details.

Similarly, you can add other users to the incident and notify them of the occurrence – voluntarily. These might be other department heads or an HR supervisor or a Line supervisor instead of the department supervisor. These users would otherwise not have access to the incident or its details.

One last thing to highlight about Basic would be the “Sensitive Incidents” feature. We will write a detailed note on sensitive incidents in another post in the future. But for now, sensitive incidents are a type of flag that limits the access on the incidents to a pre-determined group of users – Quality Managers, investigators and other management level users. QUASR does not have an opinion on how or when to use this flag. We leave it to our customers to use it as they see fit in their organisation.

QUASR Basic vs QUASR Enterprise

Lastly, as I mentioned, BASIC is Lite with a workflow. But how does Basic compare to Enterprise? Enterprise, as the name suggests, is unlimited in many ways. Enterprise targets a group of institutions as opposed to independent hospitals or providers. A group have other requirements in terms of uniformity of process across their participant hospitals. They tend to prefer a single cluster implementation where the group management can get their dashboard with the essential information they need about the overall incident performance. BASIC, on the other hand, does not support a cluster implementation. There are other differences in terms of support access, implementation, customisation provisions in Enterprise that aren’t available in Basic. For more information, feel free to reach us out, and we’d be able to give you even more clarity on both these versions and options.