Open communication is critical in fostering a safety culture and a positive work environment in healthcare. In this blog, we look at the pivotal role of online incident reporting in fostering open communication and creating a culture of safety, transparency, active learning, and continuous improvement.
Table of Contents
Open Communication and Patient Safety
Open and effective communication is critical to the delivery of safe patient care. Communication failures and inadequate clinical information sharing can lead to errors, misdiagnosis, inappropriate treatment, and poor care outcomes. Open and effective communication is particularly critical in high-risk situations, such as during patient identification and procedure matching, during care transfer and when critical information or risks emerge during care.
Various research indicates that ineffective communication among healthcare professionals is one of the leading causes of medical errors and patient harm. There is also a growing body of research on safety and error prevention which reveals that ineffective or insufficient communication among care team members is a significant contributing factor to adverse events.
Under-reporting
Under-reporting of incidents and near misses is still a common challenge many hospitals are facing. As shown in various surveys, some healthcare professionals are afraid to report incidents or speak up, despite sustained efforts to promote a culture of safety and transparency by the industry. This is in sharp contrast to High Reliability Organizations (HROs), which have a mature culture of safety, transparency, open discussion, and continuous improvement.
Under-reporting of incidents has far-reaching consequences. Firstly, it compromises patient safety and quality of care as no corrective actions are taken to prevent similar incidents in the future. This can lead to a loss of trust among patients and their families if they perceive that incidents are not being transparently reported and addressed.
Incident reporting is also crucial for learning and improving healthcare practices. Under-reporting means missed opportunities to identify system weaknesses and follow up with improvement actions to prevent similar incidents from occurring in the future. Furthermore, under-reporting of clinical incidents may have compliance, legal and financial ramifications.
Common Barriers to Open Communications
The following are some of the often-cited barriers to open communications:
- Culture of blame and fear of retribution.
- Complex operations involving multiple disciplines/teams in disperse locations.
- Fragmented processes and lack of standardization.
- Heavy workload, staff shortage, working in shifts.
- Lacking in communication and technical skills (eg. what incident details to report).
- Inadequate training or absence of patient safety communication tools (SBAR, Daily huddle, Escalation process).
- Privacy concerns, stigma, and discrimination (on patients).
In 2023, we conducted a survey on near miss reporting at a healthcare management conference. We asked survey respondents to choose the top 3 barriers to near miss reporting in their hospitals. The results are as follows:
Survey respondents also shared the top 3 initiatives they would propose to their management to encourage near miss reporting, as shown in the chart below.
The survey results highlighted the need to raise safety awareness, promote open communication and create a positive work environment.
Examples of Near Misses
The following are some examples of near miss events:
- Discrepancy between the scheduled procedure and the consent form.
- Wrong patient entering the operating room.
- Patients in the operating room without proper identification.
- Site markings are ambiguous or unclear.
- Wrong medication or dosage was almost administered to a patient but was detected before ingestion.
- Patients almost experienced a fall but were assisted in time to prevent injury.
- Mismatches in blood type or labeling, but the error was detected before transfusion occurred.
The key question is: how many such near misses occurred but go unreported? Had these near misses been reported and analyzed, improvement actions could be taken to prevent incidents from occurring and enhance patient safety.
Learning from incidents and near misses
Studies showed that root causes of near misses and adverse events are similar. Near miss occurrences are also many times more frequent than actual incidents. It means that there is a lot more data available from near miss reports than from incident reports. This is particularly useful for trend and root cause analysis.
Encouraging everyone to report incidents and near misses can help your organization to:
- Identify potential risks and hazards.
- Take preventive actions before incidents occur.
- Learn from errors.
- Be proactive.
- Mitigate financial, reputational, and legal risks.
- Most importantly, build a culture of safety and open communication.
Online Reporting Facilitates Open Communication
Online incident reporting system plays a pivotal role in facilitating open communication in several ways. It also enhances communication at various levels – from reporting persons, supervisors and managers to the quality and patient safety team and hospital management.
For reporting persons: Online system makes it easier, secure, more efficient to report incidents and near misses. A user-friendly system that allows anonymous reporting can encourage nurses, clinicians, and other healthcare professionals to report incidents without fear of retribution. A well-designed system with guided questions to capture required incident details will enable staff to provide information in a complete and consistent way. Photos and other evidence can be attached.
A comprehensive system can address the concerns of accessibility, anonymity, and confidentiality. Feedback can be provided to the reporting persons by having role-based access and making certain non-sensitive information accessible online. Over time, this can foster a culture of open communication where everyone is motivated and empowered to contribute to patient safety and continuous improvement.
For supervisors and managers: With workflow automation, supervisors and managers can be notified in real-time via email notifications. Responsible supervisors can access the information and provide input using established communication methods such as SBAR. Supervisors can also use the in-app communication features to notify the head of department and other stakeholders, the latter can in turn provide their input or comments. This ensures effective and timely team communication and information sharing.
For quality and patient safety team: By centralizing incident reports in an online system, the quality team can effectively manage and monitor all incidents. The quality team can be notified in real-time when incidents are reported. Escalation features can be triggered to alert senior management to adverse events or potential legal/media events.
Risk assessment, quality review and investigation are essential features of online incident reporting systems. In-app communication features such as chat box can facilitate team collaboration during investigation and RCA stage. Digital RCA tools can further enhance collaboration and teamwork. An online system brings efficiency and enables the quality team to manage a large volume of incidents and near misses, take improvement actions and communicate with all stakeholders.
For hospital management: Online system provides an effective communication channel to hospital management, giving them access to real-time reports, dashboards, and patient safety statistics. Periodic management reports can be generated. Online system provides visibility and transparency and data analytics for decision making. It facilitates communication with the Board and other key stakeholders.
In Closing
Online incident reporting system plays a pivotal role in facilitating open communication and creating a safety culture. It makes incident and near miss reporting easier, safer, and purposeful. Through built-in features for open discussion, feedback and collaboration, online incident reporting fosters a culture of open communication and improves patient outcomes.
QUASR is a ready-to-use, cloud-based incident reporting system with rich features that support open communication and collaboration. Contact us to learn more.
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