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The importance of near miss reporting in healthcare

Hak Yek Tan
near miss reporting

You didn’t see it coming

Imagine your hospital had just encountered its first case of wrong-site surgery. As the Quality and Patient Safety Manager, you were utterly shocked and in disbelief. How could this have happened? After all, Surgical Safety manuals and checklists are in place, and you just had a “Safe Surgery Saves Lives” campaign for Safety Week recently. You looked back at all the incident reports, searching for wrong-site surgery incidents but could not find any. Crucially, there are no near miss reports that give you warning signs that such an adverse event could happen in your hospital. “This must a freak incident”, you said to yourself.

 

Your thoughts shifted to incident reporting practices in your hospital. Your department receives many incident reports – clinical, non-clinical and workplace incidents – but very few near miss reports. Awareness on reporting near miss incidences or unsafe conditions has been low. “Why report when the error is corrected in time and the patient is not harmed?”, you heard such remarks. In hindsight, had near miss reporting been encouraged, you might have seen some warning signs and taken mitigating actions.

 

The above is a hypothetical scenario to highlight the importance of near miss reporting. It is part of proactive safety and risk management and is crucial in preventing adverse events. Data from near miss reports will enable you to identify potential risks and system weaknesses, and step-up safety measures.

Don’t leave it to chance

The following are some examples of near miss reports that would have raised red flags in the above scenario:

    • ● Discrepancy between the scheduled procedure and the consent form.
    • ● Wrong patient entering the operating room.
    • ● Patients at the operating room without proper identification.
    • ● Site markings are ambiguous or unclear.
    • ● Site markings being done without the involvement of a patient or surgeon.
    • ● Not all team members were present during time outs.

How many such near misses might have occurred but go unreported?

What is a near miss?

WHO defines a near miss as “an error that has the potential to cause an adverse event (patient harm) but fails to do so because of chance of or because it is intercepted”.

 

NHS defines near miss as any patient safety incident that had the potential to cause harm but was prevented. A near miss incident should be distinguished from a “no harm” incident, where an incident happened, but no harm resulted (for example, out of date medicine administered, but the patient suffered no ill effects).

 

ISO 45001 (Occupational Health & Safety) says an incident where no injury and ill health occurs, but has the potential to do so, can be referred to as a “near-miss”, “near-hit” or “close call”.

Near misses are not limited to clinical incidents. They include non-clinical incidents, workplace safety and health related incidents, and IT and data breach incidents.

The importance of near miss reporting

Just like incident reporting, near miss reporting plays a crucial role in the patient safety management system. Studies conducted on patient safety have shown that the root causes of near misses and adverse events are similar.  However, near misses are around 10 to 100 times more frequent than actual incidents. The large database on near misses provides valuation information for analysis to prevent incidents from occurring.

 

The importance of near miss reporting are as follows:

 

Identifying potential risks and hazards. Near miss reporting provides you with a large database for analysis to identify potential risks and hazards in the workplace. Near misses could be the warning signs of latent system failures that otherwise go unnoticed. Root cause analysis on near misses can tell you whether the existing safety measures in place are effective, or further preventive or early detection mechanisms are required.

 

Building a culture of safety. Near miss reporting can help to create a culture of safety, where patient safety is the top priority. It promotes transparency and encourages health workers to be more aware of safety concerns, and report near misses and other incidents without fear of reprisal. 

 

Learning from errors. Near miss reporting provides opportunities for learning and continuous improvement. These learnings can lead to new safety practices and sharing of skills and knowledge among health workers.

 

Mitigating financial, reputational, and legal risks. Moreover, by demonstrating a proactive approach to patient safety, management can mitigate the risk of financial and reputational losses resulting from adverse events, as well as the risk of legal liabilities.

Barriers to near miss reporting

There are various barriers to reporting near-miss events in healthcare. Chief of which is safety culture and awareness. Many people including health workers are still having the perception that if an incident does not reach the patient or cause any harm, it is not necessary to report. They are not fully aware of the importance of near miss reporting. Fear of punitive actions and blame culture are major hindrance. Heavy workload and time constraints, fear of litigations, poor feedback loop, and manual and ineffective reporting systems, are some of the common barriers.

 

How is your organisation doing in near miss reporting? A useful indicator is the number of near misses reported as a percentage of the total number of incidents reported. If the percentage is less than 10% or 20%, then you may want to conduct an internal survey to find out why people are hesitant to report near misses.

Strategies to encourage near-miss reporting

Here are some strategies that you can implement to encourage near-miss reporting. 

 

Establish a culture of safety: Creating a culture of safety is essential to encourage reporting of near misses, regardless of severity or outcome of the incidences. Promote open communication, transparency, non-punitive reporting policies and a no blame culture. Break the psychological safety barrier and make people feel comfortable to report near misses. 

Provide training and raise awareness: Emphasize the importance of near miss reporting, how it can prevent adverse events, how to identify near misses, and how to report them can help promote reporting. Healthcare workers should also learn how to intervene or respond in situations where errors are detected before reaching patients.

Recognise and reward near miss reporting: Rewarding staff for reporting near misses is an effective way to encourage reporting. It sends a strong message on management commitment to improve patient safety. Organise safety campaigns on near miss reporting and share success stories.

Implement a web-based reporting system: Make it quick and easy for staff to report near misses. Use simple forms. The system should be user-friendly, easily accessible, and confidential. Provide an anonymous reporting feature so that more people will step forward. Use the reporting system for data and trend analysis, generating actionable insights, and tracking corrective actions.

Provide feedback and be open: Provide feedback to staff who reported the near misses can help encourage greater participation. Seeing their efforts appreciated and led to a positive impact on patient safety is a great motivation. Showcase the achievements through internal newsletters and website, etc. A web-based solution can facilitate communication and collaboration.

Engage patients and their families: Encourage patients and their families to report near misses and potential safety concerns. Patient engagement plays a crucial role in patient safety, providing unique insights and perspective, and personal experience.

In summary

Near miss reporting is crucial to improving patient safety and preventing harm. It helps in early detection of potential risks and hazards, improves safety culture and awareness, and promotes transparency and learning.  Healthcare organisations should encourage and promote a culture of near miss reporting among staff, patients, and their families. Establishing a web-based system for reporting, analysing, and monitoring near miss incidences and corrective actions will be a great step forward.


Share your success stories on near miss reporting with us by emailing them to hak@healthgrc.com

QUASR is a cloud-based, user-friendly, and secure incident and near miss reporting system.

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Engaging Patients for Patient Safety

Hak Yek Tan
Patient Engagement

Introduction

The World Health Organization (WHO) has chosen Engaging patients for patient safety as the theme for World Patient Safety Day 2023. It is a recognition on the central role that patients, families and caregivers play in improving patient safety. Through the slogan “Elevate the voice of patients!”, WHO calls on all stakeholders to take the necessary actions to ensure that patients are involved in the design of policies and practices and are active partners in their own care.

 

When patients are engaged, they are more likely to be proactive in managing their health. They are also more likely to be aware of risks and raise safety concerns with providers. Patient perspective and insights are a vital source of learning and improvement. Their voices and experiences should be heard. In this blog, we take a closer look at how patient engagement improves patient safety, the challenges in patient engagement, and what healthcare providers and leaders can do in  in advancing patient engagement.

Recognizing patient’s role in patient safety

Traditionally, hospitals focus on reducing errors by ensuring compliance to policies and procedures from a systems and regulatory perspective. Staff training, process improvement and automation are the means to reduce medical errors. Generally, there is limited patient involvement in safety initiatives and procedures such as response to patient safety incidents. However, there is increasing awareness and recognition that working collaboratively with patients and families is essential to improve patient safety. 

There are good reasons to engage patients and families for patient safety. Partnering with patients and families shows that their insights and experience are valued. Patients provide unique perspective and insights that providers may lack. They are the extra sets of eyes and ears that should be integrated into safety processes. 

WHO calls patient engagement and empowerment a powerful tool to improve patient safety (WHO Global Patient Safety Action Plan 2021-2030). Accreditation agencies such as JCI requires healthcare organizations to actively engage patients in governance and patient safety strategies. This trend is further driven by Patient for Patient Safety (PFPS), a global network dedicated to improving healthcare safety through advocacy, collaboration, and partnership. 

How does patient engagement improve patient safety?

When patients are engaged, they are more likely to:

    • ●  Be well informed about their condition and treatment plans, ask questions, recognize warning signs, and give feedback.

    • ● Adhere to their treatment plans and prescribed medications. This can help to reduce the risk of adverse events such as medication errors.

    • ● Communicate more clearly and effectively with their providers. This can help to prevent errors or misunderstanding, encourage patients to speak up and ensure patients receive the right care.

    • ● Be more aware of safety concerns and issues they encounter. Patients are more likely to give feedback and valuable input for quality and safety improvements.

 

Active engagement of patients can improve adherence to safety practices. Evidence shows that when patients are treated as partners in their care, significant gains are made in safety, patient satisfaction and health outcomes. 

Patient engagement in safety efforts

Patients play crucial roles in improving patient safety in several ways. First is by actively engaged in the delivery and safety of their care. Example of patients taking ownership over their health and safety are providing their medical history accurately, taking and managing medications, reminding about drug allergies, asking for aids to avoid falls, and being compliant to the advice they receive. Patient’s active involvement can reduce non-compliant on prescribed treatment and medication that lead to adverse events.

 

Next is by speaking up, asking questions about their care, and reporting errors or unsafe behaviours which they observe. Patients are the extra safeguards for medical errors or potential mistakes overlooked by their providers. 

Patients can also be involved in the design of safety policies and initiatives by giving their unique perspectives and experience. In the recent Patient Safety Incident Response Framework (PSIRS), National Health Service (NHS) sets out a new approach in responding to patient safety incidents. Engaging patients, families and staff affected by the incident can help gain a better understanding on how incidents happen and the contributing factors. (Refer to Compassionate Patient Engagement in QUASR Incident Reporting eBook)

Barriers in patient engagement

Healthcare organizations face some common challenges in cultivating patient engagement. The most cited barrier to patient engagement in patient safety is the individual’s lack of awareness and understanding of what patient safety is, and their role in it. The other key barrier is communication. Effective communication between providers and patients is essential for patient engagement. However, different individuals may have different ability or comfort levels in expressing their needs. Patients and families may lack awareness of healthcare risks, and the implications of their conditions, making it difficult to engage them in their care and in safety practices.

Healthcare providers, on the other hand, often face time and resource constraints when engaging and interacting with the patients. Physicians and nurses need to learn the skills of engaging patients, such as how to provide proper instructions and invite patients to ask questions. Generally, healthcare systems and processes are not designed for active patient involvement. While the use of technology, such as patient portals and telehealth can improve patient engagement, some patients may not have access to these technologies or feel comfortable using them. There are also legal and regulatory issues to be considered to ensure patients’ rights and data privacy are protected and how increased patient involvement could impact provider liability.

Ways to improve patient engagement

There are several ways you can improve patient engagement in patient safety, some of which include:

 

    • ● Establish clear and effective communication channels with patients. This includes giving clear instructions and informing and educating patients on their health conditions, treatment options and risks involved.

    • ● Encourage patients to speak up on safety issues and to report incidents. This can be done by creating a culture of open communication and building trust.

    • ● Encourage patient feedback and use it to improve patient experience. This includes conducting regular patient satisfaction surveys and responding promptly to patient complaints.

    • ● Increase patient and provider awareness on safety through education and reviewing organizational policies to incorporate the patient’s perspective.

    • ● Use technology such as patient portals, telehealth services or other emerging health technologies to enhance patient engagement and patient experience.
Culture, leadership, and technology the critical enablers

It is imperative that healthcare providers make patient engagement an integral part of their culture, systems, and processes. Leadership commitment is paramount in the cultural shift towards patient centered care. Champion new policies and practices to strengthen patient engagement for patient safety. Create a supportive environment and provide resources to engage patients and families. Finally, leverage on health IT solutions as enablers of patient engagement for safer care and better patient experience.

We believe that culture, leadership, and technology are the critical enablers for patient engagement. In addition, we would like to hear your views about it at hak@healthgrc.com.

Strategies For Promoting Medication Safety in Transitions of Care

Celina B

In our previous blog, we discussed how polypharmacy significantly increases medication safety risk, especially in older people living with chronic diseases. In this blog, we will discuss how patient safety is compromised in transitions of care and what strategies must be adopted to overcome it.

Transitions of care is the patient’s movement from one healthcare setting to another or home. When patients receive care at various healthcare facilities, there is a greater chance of medication discrepancies, errors, and adverse drug reactions.

At each point in transitions of care, the medication a patient was taking prior to the transition needs to be identified by medication reconciliation. Medication reviews are vital at each transition to avoid or reduce medication discrepancies.

Medication Safety during transitions of-care

Image source: Medication Safety in Transition of Care by WHO

Medication Harm Due to Discrepancies

Discrepancies or errors that are not identified and resolved may place the patient at risk of medication-related harm. For instance, adverse drug reactions often go unidentified or undiagnosed during routine clinical screening and treatment, which puts the patient at greater risk of further harm. 

 

In addition, polypharmacy, high-risk medications, or the presence of morbidity increases the risk of a patient experiencing medication-related harm at any point during transitions of care settings. 

 

Early confirmation of medication intake and timely diagnosis and management of medication-related harm is necessary to minimize patient harm. Reporting adverse drug reaction events to the patient safety incident reporting or pharmacovigilance systems is necessary to facilitate learning at organizational, national, and international levels. 

Risks Associated with Insufficient Medication Safety

Medication-related harm affects almost every patient in the transition of care. The following are the risks associated with insufficient medication safety during transitions: 

1. Medication errors

The risk of medication errors is potentially high during transitions of care. Such errors occur when a patient has been prescribed the wrong medication with the wrong dosage at the wrong time. 

2. Medication duplication

Lack of communication between healthcare providers often causes medication duplication during transitions of care. When the patient is prescribed the same medication by multiple healthcare providers, it can lead to overdose or other adverse events. 

3. Medication discrepancy

When patients are transferred from one healthcare setting to another, there is a high risk of medication discrepancy. The difference in medication regimen in new settings arises from poor communication, manual processes, patient forgetfulness, and time constraints. Medication discrepancies cause delays in treatment and increase potential harm to the patient. 

Possible Barriers to Medication Safety

Challenges to medication safety in transitions of care are divided into three categories: 

1. Patient level barriers

1.1 Competency

Competency refers to the patient’s understanding of the use of medications. Most patients don’t have enough knowledge on how to manage medications successfully. 

 

Limited health literacy compromises the ability of patients to provide accurate medication histories at the time of hospital admission. Such inaccurate medication history leads to medication discrepancies. 

 

Moreover, patients and family members also find it hard to understand the discharge instructions. It is because of their educational level, or they may be too reluctant to ask questions. 

1.2 Insufficient engagement between patients, caregivers, and physicians

Lack of involvement of patients and caregivers with physicians during transitions compromises the quality of care. For instance, the patients and caregivers may not provide a comprehensive patient history to the physicians, which is necessary for making the right diagnosis. Additionally, they may not ask appropriate questions from healthcare practitioners regarding patient conditions. 

 

Similarly, physicians may forget to provide adequate information on the patient’s condition and care, which leads to confusion and medication errors that put the patient at risk. 

2. Health system-level barriers

2.1 Lengthy and confusing discharge paperwork

The lengthy discharge forms of hospitals complicate communication, decrease treatment compliance, increase the risk of discrepancies, and compromise patient safety. It is because written discharge instructions are long and hard for the patient and family to understand. Patients who don’t understand their medical discharge instructions will not stay compliant, which can lead to unfavorable outcomes.

2.2 Inadequate time to give health education

Limited time is another important system-level barrier. Generally, hospital staff doesn’t have sufficient time to thoroughly discuss discharge instructions with patients. When the staff cannot educate the patients, it causes confusion and compromises the quality of care.      

2.3 Poor coordination between transitions

Poor communication and coordination between transitions of care negatively impact patient safety. It occurs when different practitioners and healthcare settings are not communicating or coordinating effectively to ensure continuity of care. This can result in medication errors, unnecessary treatments, adverse medication reactions, and other serious complications.

2.4 Inadequate Workforce

Lack of workforce in healthcare settings is another cause of compromised care during transitions. When healthcare providers are overloaded, they are not able to provide necessary care coordination and follow-up services for successful transitions of care. Moreover, chances for errors to occur are high, which can cause delays in diagnosis and treatment.

3. Practitioner level barrier

3.1 Lack of communication between physicians

Poor coordination and communication among healthcare providers are commonly seen in hospital setups. It is because different physicians visit at different times and add discharge orders without even interacting with each other. This inadequate transfer of information in transitions of care puts the patient’s safety at risk and compromises care.

3.2 Poor medication reconciliation

Poor medication reconciliation during transitions of care increases the risk of medication errors, medication duplication, delays in treatment, and increased healthcare costs. It usually occurs when healthcare providers are not aware of the complete and accurate medical regimen of the patient. And they end up prescribing medication that can lead to complications and hospital readmissions. 

Potential Solutions for Ensuring Patient Safety in Transitions of Care

Optimizing patient safety as they navigate various healthcare settings is crucial. 

The following strategies should be considered to optimize medication safety at transitions:

1. Improving information management

Effective information exchange is vital for patient safety. Healthcare facilities should improve the information management process by simplifying discharge forms and introducing e-script. For instance, the discharge forms should be very simple, written in lay terminology, and organized with separate categories so the patients can easily read and understand the information. Similarly, the use of e-scripts should be established to overcome meditation discrepancies. When electronic prescriptions are sent to pharmacies, it will reduce the risk of medication harm. 

 

Health systems should switch to centralized electronic health records (EHRs) for a long-term change. It keeps the physicians connected, allows seamless transfer of information, and minimizes the risk of errors at transitions of caregivers.

2. Medication reconciliation

Healthcare professionals should be trained for proper medical reconciliation. In this process, healthcare professionals work closely with patients and their family members to ensure that complete and accurate information is transferred consistently across care transitions. 

 

Effective medication reconciliation allows caregivers to avoid hazardous drug combinations, dose changes, duplications, and adverse events. It also reduces its reliance on patients’ recall abilities and allows easy analysis of medication information for better management decisions.

3. Increase engagement between patients, caregivers, and physicians

Improved communication between patients, caregivers, and physicians is critical for reducing the risk of adverse events. 

 

Healthcare professionals should fully inform the patients and caregivers about the patient’s condition, treatment options, and expected outcomes. When the healthcare team involves patients and caregivers in the treatment process, it develops trust and makes it easier for them to communicate. As a result, they are more likely to follow the treatment plan as prescribed.  

4. Incorporating an incident reporting system

Healthcare facilities should set up an incident reporting system to ensure patient safety during transitions of care. It is designed to strengthen existing organizational processes by automating incident management workflow, performing risk assessment, providing real-time analytics and insights, and resolving incidents related to patient care.

The incident reporting system allows healthcare providers and organizations to track and report incidents related to patient care during transitions and enables them to take proactive steps to address the issue before it results in adverse events. It also helps identify areas that require improvement to ensure better patient outcomes and increased efficiency in transitions of care. 

By incorporating an incident reporting system, providers can provide valuable information that can be used to identify patterns or common causes of medication errors. 

It also allows for: 

    • ● Early identification of potential safety issues: Through a reporting system, healthcare professionals can identify the possible issue and risk factors leading to medication errors. It enables them to take quick actions to avoid future errors and ensure patient safety.  

    • ● Root cause analysis: Incident reporting systems work efficiently for conducting root analysis of the underlying cause of medication-related errors. This information helps in making targeted interventions to prevent future events which put the patient at risk. 

    • ● Quality improvement: With incident reporting systems, healthcare providers can get instant reports on their performance aimed at improving medication safety. It allows them to track their interventions’ effectiveness, evaluate their efforts’ impact, and make adjustments as needed.

    • ● Compliance: Incident reporting systems can be used to demonstrate compliance with regulatory requirements related to medication safety, such as The Joint Commission’s National Patient Safety Goals.

5. Improve coordination between different transitions of care

Coordination between transitions of care is essential for positive health outcomes of patients. It eliminates the risk of medication errors, discrepancies, and adverse events. When patients receive consistent and appropriate care throughout different stages of healthcare, it can prevent hospital readmissions and unnecessary treatments. So, physicians, specialists, nurses, and other healthcare professionals should work together to provide comprehensive and coordinated care to patients. 

6. Workforce planning

Effective workforce planning is critical for the quality of care of patients. When there is adequate staff during different stages of the healthcare journey, the patients will receive appropriate and consistent care. This results in better treatment and reduced medical costs. So, healthcare settings must identify the number of healthcare staff required to meet the demands of patients.

Conclusion

Patient safety during transitions of care is a critical concern for the healthcare industry. To overcome this challenge, a multi-faceted approach is required where organizations, practitioners, and patients must work together to ensure smooth transitions. Healthcare organizations should optimize and establish clear protocols for medication management to avoid medication-related harm. An electronic system must be incorporated to improve communication among patients and care providers. 

 

Additionally, patients should be educated about their rights and responsibilities toward their medications. All these approaches will help to reduce the risk of medication errors and improve patient outcomes. 

 

Are you planning to incorporate an online incident reporting system to improve patient care? QUASR is a robust incident reporting system, which makes it easier for healthcare settings to identify, investigate, and manage risks by implementing corrective actions.

 

Book a demo to learn more about medication reporting in QUASR.

Request Demo of QUASR

Strategies to Improve Medication Safety and Reduce Harm in Polypharmacy

Celina B
Polypharmacy

In our previous blog, we discussed high-risk situations arising from look-alike, sound-alike (LASA) medications and high-alert medications which can cause significant medication harm. In this blog, we will talk about how to improve medication safety and adopt strategies to reduce polypharmacy, a term that refers to the use of multiple medications at the same time by one person.


Medicines can provide many benefits in treating and preventing health problems. However, at times polypharmacy can be inappropriate. For example, people may still be taking medicines that are not working or no longer needed; medicines may have been prescribed to treat the side effects of other medicines or other treatment options which might lead to severe side effects or harm. Elderly people with multiple chronic diseases are the most vulnerable group in polypharmacy.

Statistics on Impact of Polypharmacy

Inappropriate polypharmacy is one of the most significant public health issues facing us today, especially amongst the elderly. Polypharmacy increases medication safety risk due to the likelihood of side effects, risk of interactions between medications and making medicine adherence more difficult. This challenge is set to increase as the population ages (in some countries) and more people suffer from multiple chronic diseases. 

 

The depth and breadth of polypharmacy’s impact on are highlighted in the following statistics:

50% of hospital admissions due to Adverse Drug Events (ADEs) are preventable. 70% of these are inpatients over 65 years of age and on 5 or more medicines.

67% of elder people are taking five or more prescription drugs, over-the-counter medications, and supplements

Polypharmacy increases the risk of ADEs, from 13%, which is associated with taking two medications, to 58%, which is associated with five drugs

8.6 million unplanned hospital admissions were caused by ADEs in Europe every year. 70% of these inpatients are over 65 years of age.

Risks and Challenges due to Polypharmacy

In general, the issue of polypharmacy mainly revolves around the elderly (65 years of age and above). Let us review some of the commonly discussed challenges, including adverse effects, medication adherence issues, and most recently the impacts of the COVID-19 pandemic.

    • ● More medication means a more complex dose schedule as well. Even if patients use a calendar to schedule dose intake, they may still experience occasional poor compliance or confusion with multiple doses.

    • ● Side effects associated with polypharmacy can create issues with adherence compliance. If a patient is taking medication that causes fatigue, they could sleep through the dosing period. Also, some medications may even cause memory loss in patients leading to double dosing (overdose).

    • ● Prescribers have tools that can help predict possible adverse drug reactions between medications, they often don’t make up for the fact that polypharmacy raises the risk that medications taken together will lead to potentially harmful interactions.

    • ● Some medications come with lengthy instructions that spell out the amount of medicine to take, how to take it, frequency of intake, and when not to take the drug so patients have the potential for getting confused due to such LASA drugs.

    • ● COVID-19 pandemic has taken a significant toll on people, which has translated to substantial increases in medication use. For instance, consumer use of antidepressant, anti-anxiety, and anti-insomnia medications increased the risk of medication errors due to polypharmacy.

Strategies and Tools to Reduce Polypharmacy

The healthcare industry has made significant collective efforts to develop tools that can help tackle the challenges inherent to polypharmacy. The following are some of the strategies and tools your organization can adopt to reduce polypharmacy, increase deprescribing, and help patients achieve substantial clinical and financial benefits.

1. Deprescribing

Deprescribing is considered one of the most effective ways to decrease polypharmacy. It is the planned and systematic process of identifying and reducing or discontinuing medications that may no longer be of benefit or may be causing harm. The main goal is to reduce the potential adverse effects of polypharmacy. This is achieved by multidisciplinary team collaboration and addressing the patient’s current needs and goals of care.

2. MAI Index

The Medication Appropriateness Index (MAI) is a set of 10 questions conceived to help clinicians make deprescribing decisions. Each criterion is rated on a three-point Likert scale. When added up, the resulting score is intended to determine the level of inappropriateness, with a score of 0, meaning the drug is appropriate, and 18 representing maximal inappropriateness.

3. Beers Criteria

The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, commonly called the Beers List, are guidelines published by the American Geriatrics Society (AGS) for healthcare professionals to help improve the safety of prescribing medications for adults 65 years and older in all except palliative settings. The Beers Criteria are intended to serve as a guide for clinicians and the criteria may be used in conjunction with other information to guide clinicians about safe prescribing in older adults.

4. STOPP/START Criteria

These two resources — the screening tool of older people’s prescriptions (STOPP) and screening tool to alert to right treatment (START) criteria — were first published in 2008 and most recently updated in 2014. The latest versions of STOPP and START include a combined 114 evidence-based criteria — up more than 30% from the original. With the STOPP/START criteria, clinicians can potentially decrease polypharmacy by improving medication appropriateness

5. SIMPATHY Analysis Tool

The goal of the SIMPATHY economic analysis tool is to provide a high-level analysis of the economic costs and benefits associated with carrying out polypharmacy reviews. The analysis follows a top-down approach and estimates maximum costs and benefits associated with activity.

Sources: Adopted from WHO, NCBI, AGS and European Commission

Conclusion

Hospital management plays a significant role in reducing inappropriate polypharmacy and ensuring medication safety. Taking a systems approach with multidisciplinary clinical and policy leadership is good starting point. Nurture a culture that encourages and prioritizes medication safety in your organization. Streamline and standardize your policies, procedures, and protocols as these are critical in managing polypharmacy risks. This applies from initial prescribing practices to regular medication reviews.
 

Adopt one or more of the strategies described above to reduce polypharmacy. Deprescribing is one of the most effective ways. Using tools and technology appropriately to support implementation can be useful and effective. This includes having an online incident reporting system for medication error reporting. Finally, educate and empower your patients with the right information to make informed decisions. This can go a long way in ensuring the safe use of medicines.

Integrating Quality, Safety and Risk Management in Healthcare

Hak Yek Tan
healthcare-quality

To deliver safer and better care, healthcare providers will need to adopt proactive risk management, system-wide thinking, process digitalisation, effective data monitoring and a culture of continuous improvements.

Medical errors still at alarming rates

Despite sustained efforts by the healthcare industry to improve patient safety over the last two decades, medical errors continue to occur at unacceptable rates globally. A study by Johns Hopkins (2020) showed that more than 250,000 people in the US die every year due to medical errors, making it the 3rd leading cause of death after heart disease (700,000) and cancer (600,000). In Australia, Grattan Institute Report (2018) revealed that one in nine patients suffers a hospital-acquired complication. This figure is not far from WHO statistics which estimates  one in every 10 patients being harmed while receiving hospital care, of which 50% are preventable.

How healthcare responds to incidents matters

The question is, why are we failing to reduce medical harm? To find some answers, a good place to start is to study how healthcare responds to incidents compared to high reliability organisations (HROs), such as airlines and chemical industries.

 

Many case studies on severe safety incidents are available in the public domain, providing great insights and learning. The airline industry conducts thorough investigation and Root cause analysis (RCA) on all direct and indirect causes, reviews procedures and takes a system-wide approach to identify the root causes of incidents. The process is transparent and carried out by independent team of experts. Findings are shared with all industry players. Changes often become industry safety protocols, while regulations are reviewed and updated.

On the other hand, case studies on medical incidents often give a different picture. We read about full blame being put on individuals, despite evidence of system failures; whistle-blower who exposed hospital shortcomings and weaknesses getting blacklisted; and misuse of monitoring devices and catastrophic clinical oversight being investigated at department level, instead of at the organizational or even manufacturer level. These are not consistent with responses expected from HROs.

Challenge our current thinking and learn from HROs

Healthcare today is a highly complex operation. We need to challenge our current thinking on management practices. One approach which has been advocated by many is to learn from safety-critical industries, and understand how these industries achieve impeccable safety records.

Compared to HROs, we often find a high level of process complexity and variation in healthcare settings. An example is incident management where each department or unit may have their own workflow. There is a general lack of system-wide thinking to understand and prioritize risks. In many cases, after investigations and RCA are completed, only short-term fixes are taken instead of profound system changes that can prevent adverse incidents from recurring.

Having a fragmented management system with silo applications is one of the reasons for quality failures and ineffective health systems. A direct impact of this is in the lack of timely and more complete data sets from different sources, critical for effective monitoring and analysis. Finally, the blame culture sadly remains a common challenge many hospitals are still facing today. People are afraid to speak up. In contrast, HROs have a mature culture of safety and continuous improvement, open discussion, and active learning.

Five key learnings

Notwithstanding healthcare sector’s unique challenges, we believe the following key learnings can help healthcare providers in developing and sustaining a culture and system to deliver safe and reliable care:

    • ● Streamlined and standardized processes
    • ● System-wide thinking to identify root causes
    • ● Proactive risk and hazard identification, mitigation, and review
    • ● Effective data monitoring, measurement, and analytics
    • ● A culture of continuous improvement and active learning
Taking an integrated, systems and risk-based approach

These key learnings and management practices call for an integrated and systems approach in managing quality, safety, and risk in healthcare. A systems approach will help us better understand how different parts of the hospital operations are impacting patient safety and influencing health outcomes, and the relationship between different elements. Policies, procedures, and processes should be designed with this in mind in to deliver better quality of care at lower cost.

 

Healthcare providers should shift from being reactive to proactive in risk and hazard identification and mitigation. Make risk assessment an integral part of quality and safety management. Take a risk-based approach in prioritizing your next quality improvement initiatives.

Risk management in healthcare should go beyond patient safety and medical liabilities. With the increasing adoption of health technologies, higher cybersecurity threats, and shortages in health workers, risk management is becoming more complex and critical in hospital management. A comprehensive framework should cover multiple risk domains including operational, clinical and patient safety, financial, strategic, human capital, technology, legal and regulatory, and the environment.

Effective implementation requires a robust, integrated platform

Having an integrated software system is essential in operationalising these practices to achieve effective management. Manual processes can be ineffective in incident and risk management, even with established processes and procedures in place. Process digitalisation is the way forward and technologies are making it possible. An integrated solution allows for linking of processes and better understanding on how various parts are impacting safety and quality of care. It enables effective data monitoring, measurement, and analysis, providing valuable insights for decision-making. Also, it can serve as a communication and collaborative platform, further enhancing a culture of open discussion and active learning.

Risk management, incident management, audit management and feedback management can form the core of an integrated system. Other management processes and functionalities that can be added are mortality & morbidity reporting, clinical quality review and training & competency management. The system can be further expanded to include workplace safety and environmental related processes such as HIRARC (hazard identification, risk assessment and risk control), chemical register and waste management. These can be implemented in phases as your business grows and processes mature.

Lastly, a platform with robust system capabilities is needed. System requirements especially for large healthcare organisations can be demanding. The platform should be configurable, scalable, and flexible to meet specific requirements in organizational structure, workflow, process routing and email notification. Robust security access control and data security is a must. Multi integration methods will be needed, as system interfaces with EMR, CRM, HR system and enterprise data warehouse are often required. Insightful reporting and data analytics can provide an aggregated view on performance and risks to the management. A solution provider with healthcare domain expertise is also a key success factor.

Embarking on your hospital’s digitalisation journey

For smaller hospitals and healthcare settings, the journey on digitalisation of quality management processes can start with online incident reporting. Studies have shown that online incident reporting encourages people to report incidents, helps to build a safety culture, and facilitates learning. A comprehensive solution with investigation, RCA, action tracking and collaborative features can help turn incident reporting into improvement opportunities in your organization.

The above article was first published by HMA on 1 September 2022. You can Click Here to access it.

Strategies to Reduce Medication Errors in High-risk Situations

Celina B
medication errors in high-risk situations

In our previous blog Medication Safety – A Priority in Patient Safety, we briefly touched on the three priority areas where medication errors are most likely to happen. These are certain high-risk situations, when patients are using multiple drugs, and during transition of care.

 

We will be discussing strategies to reduce medication errors in high-risk situations in this blog. In the context of medication safety, high-risk situations relate to those circumstances associated with a significant risk of medication-related harm, such as situations arising from look-alike, sound-alike (LASA) medications and high-alert medications. WHO has grouped high-risk situations into three broad factors:

1. Medication factors
 2. Provider and patient factors
3. Systems factors (work environment)

Medication Factors

Medication factors include the use of high-risk (high-alert) medications, often medicines with a low therapeutic index. The development of local high-risk medication lists that are regularly updated help healthcare professionals focus on particular risks in their own workplace. However, merely creating a high-risk medication list without associated risk reduction strategies will not be enough.

 

Strategies to reduce harm from high-risk (high-alert) medications

Due to the complexity of systems in healthcare, the Institute for Safe Medication Practices (ISMP) has highlighted that a single strategy for addressing the risks associated with each high-risk (high-alert) medication in the acute care setting is rarely sufficient.

The following measures may therefore be considered to ensure medication safety:

    • ● Maximize access to provide necessary information on medications when critical tasks are being performed.

       

    • ● Standardize clinically sound, uniform models of care or products to reduce variation and complexity.

       

    • ● Simplify the number of steps in the process of handovers without eliminating crucial redundancies.

       

    • ● Keep antidotes, reversal agents or remedial measures readily available and ensure staff are appropriately trained to manage such errors.

    • ● Proactively identify risks and minimize their effects. Built in safeguards to prevent or respond to failures.

Provider and Patient Factors

Provider Factor

Provider factors may be related to the healthcare professional providing patient care or the patient being treated. Poor prescribing practices by healthcare professionals include over-prescribing, under-prescribing and misprescribing. All of these potentially inappropriate prescribing can contribute to an unfavorable risk–benefit ratio, and reduce the benefits of these medications to the patient.


Healthcare professionals are also involved in ensuring safe storage, preparation, dispensing, administration and monitoring of medications. These different steps of the medication use process are no longer the sole responsibility of any single healthcare group. However, it is vital that there is good communication between different groups of healthcare providers. 

Resource-limited healthcare settings are often characterized by a lack of electronic support systems for prescribing or dispensing, overcrowding of patients, staff shortages and inadequate monitoring. In such circumstances poor prescribing practices, such as the use of error-prone abbreviations or illegible handwriting increase the risk of medication errors.

Patients Factor

It is well known that adverse drug events occur most often at the extremes of life (in the very young and elder people). In elderly, who are likely to be receiving several medications concomitantly, adding to the risk of adverse drug events. In addition, the harm of some of these medication combinations may sometimes be synergistic and be greater than the sum of the risks of harm of the individual agents.

Polypharmacy was the second major factor predicting risk of experiencing a medication error in adult inpatients and increased risk of harm.

Multi-morbidity is becoming more prevalent as life expectancy increases in many countries around the world. A meta-analysis that included 75 studies from primary care demonstrated that mental-physical multimorbidity was associated with an increased risk of harm.


High-risk medical conditions predispose patients to an increased risk of adverse drug reactions, particularly renal or hepatic dysfunction and cardiac failure (where both kidney and liver can be compromised together).

 

Strategies to reduce medication errors related to provider and patient factors

There should be a systems approach to counter the effects of human fallibility. This approach concentrates on the conditions under which people work and endeavors to build the defenses required to avert errors or limit their effects.

    • ● At the prescribing level: pharmacist/nurse to ensure appropriate medicine, dose, route and duration written for the right patient in the prescription by a certified medical practitioner.

    • ● At the storage level: Ensuring medications stored accordingly to the right storage conditions and right labeling. Also, best arrangement practices are often associated with LASA and FIFO principles (LASA – Look Alike, Sound Alike & FIFO – First In First Out).

    • ●  Standardizing the medication preparation, dispensing and administration following the rights – either 6R, 7R or 10R, whichever applies to the organization’s policy.

       

    • ● Inter-professional educational initiatives may help healthcare professionals to learn to work better together in multidisciplinary teams to promote patient safety.

       

    • ● Principles of co-production of resources and partnership with patients and caregivers should be applied in relation to developing systems.

       

    • ● Core prescribing competencies are relevant to all the prescribing providers who are faced with addressing the increasing burden of complex polypharmacy.

       

    • ● Patients should be supported by an effective prescribing team working in close partnership to ensure they are aware of the purpose of all medications taken, their likely benefits and potential risks.
Systems Factors

Systems factors (work environment) include the hospitals and high-risk situations within those settings (e.g. risks associated with perioperative or neonatal care). The environment in hospitals can contribute to error-provoking conditions. The clinical ward may be busy or understaffed, contributing to inadequate supervision or failure to remember to check important information. Interruptions during critical processes (e.g. administration of medicines) can also occur, which can have significant implications for patient safety. Tiredness and the need to multitask when busy can also contribute to medication error.

Strategies to reduce medication errors related to systems factors

    • ● Developing a plan to achieve those objectives, including the processes, systems, patient involvement and training of healthcare professionals.

    • ● Automated healthcare technologies are the greatest potential for dramatically reducing the incidence of harm caused by medication-related errors in the work environment

    • ● Tables giving information on drug–drug interactions, and interactions with traditional and complementary medication are also helpful, particularly in situations where polypharmacy is common.

    • ● Prescribing assessment tools can also be helpful. Building on the original Beers Criteria (for potentially inappropriate medication use in older adults), the STOPP (Screening Tool of Older Person’s Prescriptions) criteria has been developed to highlight potentially inappropriate medications.
Conclusion

Medication errors account for 50% of all preventable medical harm globally. It is an area that requires urgent actions by all stakeholders. Appropriate strategies should be implemented to reduce medication errors in high-risk situations involving medication factors, provider and patient factors, and systems factors. These strategies can form part of your organization’s patient safety programs to reduce the risk of medication errors, supported by a strong patient safety and reporting culture, along with training and feedback loop.

QUASR incident reporting system has built-in incident types including medication errors. It has pre-configured forms to capture the type of medication error, severity, type of medication/ substance involved, incorrect action, incorrect dose, and other relevant information. These forms are easily configurable to suit various healthcare settings. Hospital management can gain useful and actionable insights from the medication error reported and dashboards generated.

Book a demo with us to find out medication error reporting in QUASR

Request QUASR Demo

Medication Without Harm – A Priority in Patient Safety

Celina B
Medication-Safety

Image Source: WHO

Are medication errors one of the most frequently reported incident types in your hospital? What can be done to prevent medication errors? Is medication-related harm avoidable? According to the WHO, unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care globally. Medication-related harm represents 50% of all preventable harm in medical care and remains a critical patient safety issue.

Against the backdrop of Covid-19 pandemic, ‘Medication Safety’ has been aptly selected as the theme for World Patient Safety Day (WPSD) 2022, with the slogan ‘Medication Without Harm’. This year’s campaign also provides a platform to reenergize the WHO Global Patient Safety Challenge: Medication Without Harm launched in 2017.

 

QUASR joins the WPSD campaign to promote awareness and urge all stakeholders to address medication safety as a priority in patient safety across all levels of healthcare.

Objectives of World Patient Safety Day 2022

The objectives of WPSD 2022 are as follow:

 

  • 1. RAISE global awareness of the high burden of medication-related harm due to medication errors and unsafe practices, and ADVOCATE urgent action to improve medication safety.

    2. ENGAGE key stakeholders and partners in the efforts to prevent medication errors and reduce medication-related harm.

  • 3. EMPOWER patients and families to be actively involved in the safe use of medication.

  • 4. SCALE UP implementation of the WHO Global Patient Safety Challenge: Medication Without Harm.

Source: WHO WPSD 2022

Important Factors that Influence Medication Errors

Medication errors occur when weak medication systems and human factors such as fatigue, poor environmental conditions or staff shortages, task, and the primary-secondary care interface affect the safety of the medication process. This can result in severe patient harm, disability and in some cases even death.

List of factors that influences the medication errors:

●  Lack of therapeutic training

●  Inadequate drug knowledge and experience

●  Insufficient knowledge of patients record

●  Overworked or fatigued healthcare professionals

●  Physical and emotional health issues

●  Poor communication between healthcare professionals and patients

●  Lack of standardized policies, protocols and procedures

●  Issues with physical work environments (eg: lightings, and ventilators)

●  Complexity in naming of medicines, labeling and packaging

●  Limited quality of communication with secondary care

●  Distractions and interruptions by other staff or patients

What Can Organizations Do to Enhance Medication Safety?

All medication errors are potentially preventable. They can be greatly reduced by improving the systems and practices of medication prescribing, transcribing, dispensing, administration, and monitoring. A fundamental step in enhancing medication safety is that healthcare organizations must be familiar with the medications that are available to treat their patients. There are several ways to accomplish medication safety:

    • ► Maintain up-to-date references of current medications and have those references available at the time the drug is prescribed.

    • ► Proper container labels to help healthcare providers and patients select the right drug. If a drug is made in multiple strengths – e.g., 5 mg, 10 mg, and 25 mg, – the labels of those three containers should be easy to differentiate.

    • ► In depth knowledge of potential interactions between a newly prescribed medication and other medications already being used by the patient, including non-prescribed medications and supplements, as well as treatments being considered.

    • ► Recognize the potential risk of high-alert medications, those drugs that bear a heightened risk of causing severe patient harm if there is an error in the medication-use process.

    • ► Electronic prescribing (also known as e-prescribing) refers to a prescriber’s ability to electronically send an accurate, error-free, and understandable prescription directly to a pharmacy from the point-of-care

    • ► Medication orders should be legible and must include the following components: name of the drug, dose, route of administration, frequency, reason or conditions under which the drug should be prescribed, and patient’s weight and age

    • ► Engaging the patient in their own care may improve adherence, patient satisfaction, and also reduce opportunities for medication errors. This requires the concerted effort of all members of the medical team, both in and out of the hospital.

    • ► Automated healthcare technologies are the greatest potential for dramatically reducing the incidence of harm caused by medication errors. Equally important is the fact that their effect depends on the success with which they are integrated into well-designed care processes.

Priority Areas to Prevent Medication Errors

WHO has identified three key areas to focus on to protect patients from medication harm. Medication errors are more likely to occur in certain high-risk situations, when patients are using multiple drugs, and during transitions of care.

 

A. High-risk situations

The impact of medication errors is greater with treating inpatients in a hospital. This may be related to the more acute clinical situations in these settings and the use of more complex medications. Young children and the elderly people are more susceptible to its adverse effects. Medication errors in such scenarios often involve the administration of the wrong dose and a failure to follow proper treatment regimes.

B. Polypharmacy

Patients using four or more drugs at the same time are also in a critical situation and extra care should be taken to prevent harm. Polypharmacy increases the likelihood of side effects, as well as the risk of interactions between medications, and may cause severe harm. If a patient requires many medicines, they must be utilized in an optimal manner, so that the medicines are appropriately prescribed and administered, to ensure that they produce significant benefits with minimal side effects.

C. Transitions of care

Patients are at greater risk during transitions of care. For example: a transfer from the emergency room to the intensive care unit, from a specialty center to a bigger hospital, from a primary care doctor to a specialist, or from one nurse to another during a shift change. Serious mistakes can and do occur at these times.

Source: Adopted from WHO Global Patient Safety Challenge: Medication Without Harm

Next Steps

The Global Patient Safety Challenge on Medication Safety launched in 2017 set a goal of reducing the level of severe, avoidable harm related to medications by 50% over 5 years, globally. It is an inspirational goal. We tried to look for some statistics to see how far we have progressed over the last 5 years but could not find any. We believe gathering reliable data for measurement and comparison is a big challenge.

For healthcare organizations, perhaps you want to focus on capturing medication safety incidents in your hospital and learning from them.  To do it effectively, quality and risk management teams can adopt digitized incident reporting systems to capture, investigate and analyze root causes of medication errors, especially in the high priority areas described above.

 

In the upcoming blogs, we will deep dive to discuss medication safety in high-risk situations, polypharmacy and transitions of care in detail.

Book a demo with us to find out medication error reporting in QUASR with

  • ● Digitalized workflow and notifications
  • ● Configurable medication error types and forms
  • ● Categorizing medication errors
  • ● Risk assessment, investigation, RCA and more
Request QUASR Demo

Participation Matters!

Abishek Goda

Active participation is an essential ingredient of all successful systems. Incident or Risk management is no exception to this. In this article, we understand why active staff participation is critical to all successful implementations. We will also explore a few ideas on how you can leverage this in your systems as well. Lastly, we add a note on how QUASR achieves this for you in the Incident Management space.

Participation-Matters

Participation

Active participation, we define, is the level of engagement users have with a system. In an incident management system, this can be the familiarity and comfort that users have to report an incident or an issue using the system. In common parlance, there are metrics like daily active users (DAU) or monthly active users (MAU) used to define how successful a software system is. However, in Incident or Risk management systems, these metrics are not very useful indicators. We measure participation as the willingness to interact with the application for these cases.


Interestingly, the only way to unlock the full potential of an incident or risk management system is by optimizing for high DAU. We need all the staff to play their role in ensuring incidents are handled with sufficient detail to ensure they don’t occur again. Except, this is not something that the software provider can manage. The organization needs to facilitate and encourage this as part of its culture.

Factors Affecting Participation

A common problem with most enterprise systems is the user attitude to the system. Multiple factors influence the user perception of the system: organizational stand on the system; hierarchy and their position within that; whether the system feels intimidating; and how welcome they feel when they do participate in the process. For an incident management system, however, a lack of active participation results in poor outcomes. If the system does not capture as many incidents as possible, the organization cannot improve its safety process. Or if the incidents reported are not analyzed, investigated, and brought to a closure in a timely fashion – again, the organization cannot improve its safety process. In both these cases, the problem might be that users are not playing the role required to ensure the overall success of the process.

Secondly, incidents are not the domain of any particular staff of a hospital. For instance, caregiving is exclusive to doctors or nursing staff, just as dispensing is exclusive to pharmacy staff. But when an incident occurs, everyone from the nursing staff, pharmacy staff to janitorial staff, and service providers that are peripheral to the organization have an essential role to play — report the incident and help in whatever way they can to ensure a smooth closure and learning from the incident. 

Investigation of an incident or its root cause analysis is a group activity. In many cases, each hospital has its designated and identified experts at running this activity. Despite their expertise, the investigation staff cannot conduct a productive root cause analysis if the staff who understand the incident or the process do not come forward with their viewpoints and suggestions. Often, though, staff might quickly feel intimidated to participate amidst experts and refrain from voicing their opinions. Users on the ground may have a slightly different perspective of the issue and have important insights. Their lack of participation denies the organization a chance at improving the process!

Similarly, staff should not feel like they are “on the hook” for their participation. The environment to encourage participation is very forgiving and open in nature. The management usually needs to step up, ensure a safe space for all their staff, and encourage them to do the right thing. From the perspective of patient and worker safety, the only way forward is inclusive of all stakeholders.

Lastly, an overlooked reason for the lack of participation is that the user interface is very complicated and intimidating to use. When the quality or risk management teams implement a digital solution to their process, they are often focused on the process and forget the importance of keeping things simple. As the understanding goes, it is pretty complicated to design a simple system and is quite simple to design a complicated one. When designing a system, we often optimize for the results and impacts but fail to account for ease of use; users need to participate actively to achieve the results.

How Does QUASR Achieve This For You?

A core tenet in the design of QUASR is user participation. QUASR builds on the best practices commonly used elsewhere in the software industry. Our user interface and usability are very similar to hugely popular apps like Facebook or Gmail. Similarity with other popular applications helps us leverage the familiarity that the users already have. 

Secondly,  QUASR brings multiple simple but niche features like save draft, multi-stage forms, flags, and widgets to simplify how a user sets to achieve their tasks in the incident. Further, we have features like pseudo-anonymity to encourage participation without fear of repercussions. The list is exhaustive, and covering them all would become a blog post on its own. Feel free to talk to us to understand how you can benefit from using QUASR in your organization.

QUASR Feature: Sensitive Incidents

Abishek Goda
QUASR-Feature-SensitiveIncidents-Header

One of the core tenets of QUASR is transparency and knowledge sharing. In some sense, these two go hand in hand in most cases. Knowledge sharing happens when there is transparency within the community or organization. Incident Management is an essential first step to many organizational improvements. Pro-active Risk Management uses Incident Management as one of its drivers, for instance. Awareness of the incidents that occur in the hospital helps the management plan their mitigation and ensure they do not affect their facility’s overall quality and safety. Similarly, tracking and investigating incidents usually gives valuable inputs to quality and safety policy that every institution’s staff is aware of intimately.

Incidents, sometimes, have information that cannot be widely disseminated or discussed across all staff. We can identify many reasons why this is the case: maybe the people involved are highly placed individuals in the society; perhaps the event has a far-reaching impact if mishandled, or maybe there are legal reasons to restrict the audience. General dissemination of such information can lead to gossip or widespread speculation. In the era of viral social media, the organization may be dealing with a PR nightmare while managing the actual issue or incident. Besides, such speculation can also cause unintentional and unfounded concerns to staff or patients.


It is, then, only natural that Senior management and Quality Managers will want to restrict the audience of specific incidents to a select staff only.  

Sensitive Incidents are the digital equivalent of a “Private & Confidential” document of the paper-office era.

Sensitive Incidents in QUASR

We, at QUASR, recognize this problem very well. While we want to build a transparent, knowledge-sharing platform, we also want to enable our customers to restrict information to a restricted group of staff as the need arises. This feature is a standard feature built into QUASR and is available for all BASIC and Enterprise plan customers.

The LITE plan does not include this feature since the plan only targets a closed group of users within the larger institution. If enough customers feel LITE should have this feature, we will enable it for that plan.

Sensitive Incidents in BASIC

In BASIC, any user with sufficient privileges can mark an incident as Sensitive. Sensitive incidents in the BASIC plan have a fixed behaviour for all our customers. Only users with the privilege to view such incidents are allowed to view all parts of the incident. Other users can only access the basic incident information and supervisor review information. Similarly, access to widgets is also limited to users with access to sensitive incidents. Only users with sensitive incident access can attach files, invite other participants, and add new notes to such incidents.

Sensitive Incidents in Premium

The premium plan has two significant differences from the BASIC plan. In the premium plan, the sensitive feature is in quality manager access. By default, the quality manager is the only role that can mark an incident as sensitive. The Quality Manager role is the primary stakeholder in the premium plan for incident management, hence this decision. However, it is possible to configure and extend this to other roles at the time of implementation.

Secondly, we implement the sensitive feature as a “flag” in the system. Doing so allows us to extend all the additional benefits of the flag to the sensitive flag. Flagging an incident adds a visual cue to the incident view to indicate the flag. It also notifies a predefined set of stakeholders about the occurrence of a sensitive incident. Additionally, these predefined stakeholders automatically gain access to the incident — even if they are not initially involved in the incident. We will dedicate another post in the future to discuss the flag system in QUASR.

Premium and BASIC versions treat the access to the incident information similarly. Whereas the role and its permissions determine the behavior in BASIC, Premium restricts access to Quality Managers, Administrators, and Management roles. Again, in Premium, it is possible to configure this behavior to the organization’s specific needs

Striking A Balance

In QUASR, by implementing this feature, we forgo transparency and open communication. However, we believe we have struck a middle ground between restricting access and openness. The primary incident information remains accessible to all staff at all times. Only the more advanced information like Quality Review or Investigation and RCA details are unavailable to all users. We believe this still allows all stakeholders to stay updated on all their concerning incidents in the organization.

How does your organization handle sensitive incidents? Whether you use a manual or a paper-based system or a digital system to manage your incidents, please let us know your thoughts and suggestions on this feature.

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What can Healthcare Sector learn from Aviation Industry?

Abishek Goda

Ever since we spoke to Dr. Rosas, we have been wondering how healthcare safety can learn from the aviation industry – which, despite being nascent compared to healthcare, is reputed for its safety standards. We did much studying, and this article is a distillation of our thoughts. We have included all our references at the end of this article – as it turns out, we weren’t the first to ask this question!


Two seemingly different industries: What do they have in common, and where do the differences begin?


If one looks at it objectively, the conclusion one can draw is that although they are vastly different, they have many mutual lessons that can benefit each other. Over the last century, the aviation industry has seen massive growth, be it air traffic or the expansion of travel to different parts of the world. The sector has also secured a name for itself in terms of passenger comfort, safety, and, in most cases, timeliness. On the other hand, the healthcare industry has existed for more than a century and has seen many changes in treatment methods, care for patients’ wellbeing, and newer scientific discoveries for better health.


So, the question arises then: What can a sector created for transporting people and cargo by air have in common with the healthcare sector that deals with patients and treatment?

To give a fair picture, let us see some areas where we can compare the two, and the healthcare division can imbibe some lessons.

Safety

By and large, the aviation industry had the privilege of understanding what safety is regarding passenger and crew management. Use of Incident Reporting is one of the successful ways this is implemented. IR is a term familiar to many sectors and plays an essential role in preventing safety hazards or repeating errors. The aviation industry follows a standardized protocol for IR, which focuses on the larger picture and does not place all the accountability on the pilot alone.

Both pilots and doctors are professionals that hold the responsibility of safeguarding lives. Often errors have significant, irreversible consequences in either field. Yet, despite the high risks, the aviation industry leads IR with a blame-free atmosphere. A culture that is “open” and focused on learning allows the concerned parties to report incidents without the fear of adverse consequences. In the health industry, the report is often downplayed, leading to the repetition of an error. Healthcare requires an openness to modify policies without shifting the blame onto the staff or the members concerned.

 

One of the most successful ways the Aviation industry has ensured the safety protocols of its consumers is by adopting worldwide standards of secure transport. Many of us are familiar with the NTSB (National Transportation Safety Board). The NTSB takes on much responsibility when there is an accident. The incident is treated with grave seriousness, immediately catapulting a series of investigative reports regarding manufacturing, operation, and administration. This process guarantees that a quick decision is made and thus, lessens future debacles. When an incident occurs, the NTSB, given its integral influence on Aviation, is eligible to conduct a parallel investigation with the concerned Aviation system. The overall process has been largely effective in reducing fatality rates.

While the NTSB is a U.S-based organization, its standardization works across various countries. This two-layered work on incident reporting, where Aviation Boards work in solidarity with a larger system, has considerably played a critical role in increasing aviation safety.

Communication

In many sectors, employees downplay incidents for various reasons – one of the crucial reasons is the fear of losing employment. When an IR is created in the aviation industry, meetings discuss the incident, and there is no question of terminating employment. This openness to discussion discusses what had taken place and goes a step further in filling up gaps in communication. Aviation has a “Crew Resource Management” system, a system specifically designed for training on the job and facilitating professional communication. This system is where the airline crew, including the pilots and the flight attendants, and the ground crew and anyone involved with the airline communicates, and their cooperation dramatically reduces the risk of imminent danger.

Journaling is another vital aspect of airline staff that has helped the sector blossom. Pilots often write about their experiences of navigating a flight after landing. These journals are first-person accounts, maintained with details that may be both positive and negative, discussing the troubles faced during the flight and the overall journey. The crew are not penalized for sharing the mistakes in the journal. Every meeting is a step to betterment. Sharing the journal with the larger group of employees helps maintain transparency and leads to prevention. 

Understanding that passenger safety is of paramount importance and conceding that risk affects both the passengers and the crew, the open and learning culture of the aviation industry has come a long way in terms of care

Standardization

Indeed, the industries are different in terms of their period of existence, aim, and intricacies of customized caregiving. However, one significant learning that the aviation sector can provide is in terms of standardization. 

For airlines, the procedures are standard. From equipment, training, the language used to the IRS; the essentials are all well-structured and easy to follow for those involved. Most procedures in the aviation industry do not need second-guessing since all the information is readily available, including external factors such as imminent weather conditions, thereby reducing the risk of an unexpected catastrophe.

However, despite the differences that the healthcare sector faces from patient to patient, implementing standardized procedures for IRS or training the staff would greatly add value and be a step towards betterment

Responsibility

The final section is an overview of the workforce involved in either industry. When issues occur, an investigation is often conducted nationwide or even internationally for the aviation sector. However, many of the incidents in hospitals are only locally addressed and do not receive widespread attention unless for exceptional reasons. Doctors and staff are often at the receiving end of criticism, and the effects are long-lasting. Even minor incidents in aviation garner media attention. This attention contributes to an efficient working atmosphere in the aviation sector. Governing bodies created to address issues and almost infallible checklists to verify the smooth functioning of an airline, both on the ground and in the air, has primarily created a positive customer experience.

Aviation ensures an atmosphere of zero anxiety both for the staff and the passenger while placing enormous importance on comfort and safety. While healthcare organizations and national health governance bodies carry out significant reforms frequently, the lack of a centralized body responsible for investigation and policy formation leaves the individual organizations on their own regarding patient safety

To Conclude

There are many reasons why we cannot compare the healthcare industry to the aviation sector. The above are some aspects the two industries are similar. Over the years, the healthcare sector has seen much positive change, and these suggestions can only steadily contribute to a healthier future, mindful of safety and transparency.

References

Beentjes, Bianca (August 20, 2020). “What can the aviation sector teach the healthcare sector about safety?” Accessible here.

 

Dhand, Suneel (April 7, 2016). “Here’s Why You Can’t Compare Healthcare to the Airline Industry.” Accessible here.

 

Hunter, Greg. (September 27, 2017). “Healthcare Can Learn From the Aviation Industry About Safety” Accessible here.

 

Kapur, N., Parand, A., Soukup, T., Reader, T., & Sevdalis, N. (2015). Aviation and healthcare: a comparative review with implications for patient safety. JRSM Open, 7(1), 2054270415616548. Accessible here.

 

Meiners, John (June 13, 2019). “What can healthcare learn from the airline industry?” Accessible here.

 

Parmar, Hemraj (September 19, 2014). “Lessons for the Healthcare Industry from the Aviation Sector.” Accessible here.

 

Rice, Stephen ( February 7, 2020). “What Can Healthcare Learn From Aviation Safety?” Accessible here.

 

Swartz, Martha K. Swartz (2015). “What Health Care is Learning From the Aviation Industry”. Journal of Paediatric Health Care, Vol 29 Number 1. Accessible here.