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 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

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 prescribers 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

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.

 

Incident Reporting in Healthcare: A Complete Guide (2021)

Abishek Goda

Hypothetically, if you ask someone where you are likely to meet with an accident — in a hospital or while driving a car — most people will say hospitals are the most unlikely place to get injured.
  

Unfortunately, the actual medical situation is a bit different compared to a hypothetical situation. According to a 2015 study by the UK National Health Services (NHS), it is believed that 10% of critical accidents occur in all hospitals. 


Even the World Health Organization (WHO) has estimated that 20-40% of global healthcare spending goes waste due to poor quality of care. This poor healthcare quality leads to the death of more than
138 million patients every year.

Patient safety in hospitals is in danger due to human errors and unsafe procedures. Everyone makes mistakes, even good doctors and nurses. However, by recording those errors, analyzing and following up, we can avoid the future occurrence of errors/accidents.


To err is human, they say. The best thing we can do as humans is to learn from these mistakes and avoid repeating them in the future. When we adopt this feedback approach in hospitals and other healthcare spaces, we can improve patient safety in healthcare.


Knowing why, when, and how to report an incident can help improve patients, hospital staff, and organizations’ safety. This guide will walk you through all the different aspects of incident reporting in healthcare. It will show how to file an accurate incident report to establish high healthcare standards worldwide.

What Does Incident Reporting in the Healthcare System Means?

To err is human, to cover up is unforgivable, and to fail to learn is inexcusable."

Prof Liam Donaldson (WHO Envoy for Patient Safety)

An incident is an unexpected event that affects patient or staff safety. The typical healthcare incidents are related to physical injuries, medical errors, equipment failure, administration, patient care, or others. In short, anything that endangers a patient’s or staff’s safety is called an incident in the medical system.

The process of collecting incident data and presenting it properly to action is known as ‘Incident Reporting in Healthcare.’ With incident reporting, an emerging problem is highlighted in a non-blaming way to root out the cause of the error or the contributing factors.

Designated staff with authority to file a report, or staff who has witnessed an incident firsthand, usually file the incident report. Usually, nurses or other hospital staff file the report within 24 to 48 hours after the incident occurred. The outcomes improve by recording incidents while the memories of the event are still fresh.

When To Write Incident Reports in Hospitals?

When an event results in an injury to a person or damage to property, incident reporting becomes a must. Unfortunately, for every medical error, almost 100 errors remain unreported. There are many reasons for unreported medical incidents, but not knowing when to report is one of the most common ones. 


Unfortunately, many patients and hospital employees do not have a clear idea about which incidents to report. Knowing when to report in hospitals can boost safety standards to a great extent.

Let’s consider these situations:

✅ A nurse is helping a patient walk from his bed to the bathroom. However, he stubs the big toe on his left foot on the IV pole that he is dragging.

✅While injected the accident patient’s IV with pain medication, the nurse misread the label and administered a heavy dosage than prescribed, which increased the patient’s blood pressure level. 


In these situations, it is necessary to fill in the incident reports. Simply because an unexpected event occurred and lead to harm, it doesn’t matter how severe or minor the incident is. It is essential to report all incidents.

 

Purpose of Incident Reports

Incident reports provide valuable information to hospital administration facilities. They capture data required to highlight necessary measures to improve the overall safety and quality of the hospital. An accurate incident report serves multiple purposes.

1. Root Cause Identification

All incidents have a cause. Mishaps are pretty uncommon in hospital settings, and most incidents can be root caused by a potential reason. Correcting the root causes can easily avoid future incidents of that type. In this sense, root cause analysis of an incident is an essential investigation step for all hospitals to ensure their staff and patients are safe under most conditions.

2. Policy and Process Improvements

 

Some incidents are part of a larger pattern that can only be identified by looking at them together – let’s say, for example, through a Swiss cheese analysis model. Such assessments usually identify more significant issues that aren’t immediately apparent from individual incident reports or investigations. These assessments feed into clinical risk management as well as help guide the hospital administrators to tweak their policy or process guidelines to help staff adhere to a safer care routine. 

 

For example, let’s take a pattern of incidents. Each has a root cause individually to what looks like a handover issue – but at different stages or different type of facilities. It would be possible to tweak each of these handover processes individually to fix that specific issue. However, it may be more productive to improve the overall handover process by taking all the incidents as a whole and tweak to address them together.

3. Clinical Risk Management

 

All hospitals have and use their enterprise risk management processes. Clinical risk management, a subset of healthcare risk management, uses incident reports as essential data points. Risk management aims to ensure the hospital administrators know their institution’s performance and identify addressable issues that increase their exposure. And the ability to assess clinical risks ensures the hospitals can stay ahead in their business and provide high-quality care and a safe workplace for all staff.

 

4. Continuous Quality Improvement (CQI)

 

All hospitals have continuous improvement plans that help them stay updated with all the latest developments in patient safety and quality by assessing, evaluating, and improving their processes and methods over time. Having incident reports duly filled and followed up to closure helps the CQI process to identify potential areas of improvement and help the organization achieve a more successful CQI cycle that takes them forward.

 

5. Better Training and Continuous Learning

 

Incident data are essential sources of knowledge and on-the-job training material. Incident investigation is a rich source of information that will help new staff understand why the hospital has a specific process that may differ from their previous workplaces. Similarly, having a robust incident management system helps implement a good continuous learning program for the staff that helps them learn the most important details they need to be efficient in their day-to-day work.

 

Different Types of Incident Reporting in Healthcare

An incident is an unfavorable event in health organizations. But, the nature of the incident can vary based on numerous circumstantial factors. Broadly, there are three types of incident reports:

1. Clinical Incidents

A clinical incident is an unpleasant and unplanned event that causes or can cause physical harm to a patient. These incidents are harmful in nature; they can severely harm a person or damage the property.

For example—

● Nurse administered the wrong medication to the patient. 

● Unintended retention of a foreign object in a patient after a surgery. 
● Blood transfusion reaction.

2. Near Miss Incidents

Sometimes an error/unsafe condition is caught before it reaches the patient. Such incidents are called “near-miss” incidents. However, the problem might have diffused before the severe harm, but it is still essential to report near-miss incidents. Nearly 50 near-miss incidents occur for each injury reported.

 

For example—

● A nurse notices the bedrail is not up when the patient is asleep and fixes it. 

● A checklist call caught an incorrect medicine dispensation before administration. 
● A patient attempts to leave the facility before discharge, but the security guard stopped him and brought him back to the ward.

 

3. Non Clinical Incidents

Non-clinical incidents include events, incidents, and near-misses related to a failure or breach of EH&S, regardless of who is injured or involved.

For example—

● Misplaced documentation or documents were interchanged between patient files. 

● A security mishap at a facility.

4. Workplace Incidents

A work accident, occupational incident, or accident at work is a discrete occurrence that can lead to physical or mental occupational injury. The workplace incidents are related to mental as well as physical hurts. According to the BLS’s Workplace Injuries and Illness News, nursing assistant jobs have the highest incidence rates.

 

For example—

● Patient or next-of-kin abuses a care provider – verbally or physically – leading to unsafe work conditions. 

● A healthcare provider suffered a needle prick while disposing of a used needle.

 

Who Prepares Incident Reports in Healthcare Facilities?

At QUASR, we believe all staff (and patients, too) should be able to report incidents or potential incidents they have witnessed. But in practice, it is a bit different. Some hospitals have designated persons who are authorized to file the reports. In some other hospitals, the staff usually updates their supervisor about an incident, then can file the report. 

QUASR clients, usually, have configured to give access to all their staff so that they can initiate an incident report enabling them to stay aware of all the issues that occur – however minor or inappropriate it may be. Allowing all staff to report requires a training effort from the quality and safety teams to ensure all the employees understand what and when to file an incident report

incident-reporting

Critical Components of Incident Report

One comprehensive incident report should answer all the basic questions — who, what, where, when, and how. Most hospitals follow a preset reporting format based on their organizational needs. However, an incident report must cover the following aspects:

1. General Information

The well-informed incident report needs basic information such as the date and time of the incident. Additionally, for future analysis, your report must include general information.

2. Location of the Incident

Specifically, mention the location of the incident and the particular area within the property—for example, patient X fell in Ward no. 2 near the washroom. With the location specifications, administration staff can better investigate the reason behind the incident and fix it.

3. Concise yet Detailed Incident Description

The incident description needs to be clear and meaningful — don’t use vague language, never add baseless information, and keep personal biases out. Whenever you have to add your opinion to the report, mark it as an assumption or subjective opinion.

4. Type of the Incident

You should define the nature of the incident while reporting to get a clear view. We can categorize the hospital incidents into different sections such as Medication Error, Patient Fall, Equipment Damage, Abuse, Pressure Ulcer, Radiation, Surgery/Anesthesia, Laboratory related, Security, Harassment, Loss or damage to property, Patient Identification, among others. QUASR offers 25 such incident types built-in by default.

5. Information of all Parties Involved in the Incident

The administration needs the name and contact details of all the parties involved in the incident. The report should capture all the relevant information required to follow up with the involved parties.

6. Witness Testimonies

If there are witnesses available to the incident, it will be helpful to add their statements in your report. While writing witness statements, focus on the following attributes — specific details provided related to the incident, use quotation marks to frame their accounts, note witnesses’ location at the time of the incident, and how they are related to the incident.

7. Level of Injury

In case of injury, the reporting staff must record the injury level and cause in the report. If the incident involves an in-patient at the hospital, their medical records will reflect the treatment and diagnosis of the injury. However, for others, it might be required to follow up and record their injury diagnoses.

8. Follow Up

The incident report is incomplete without the follow-up action details. Each report should include remarks stating what preventive measurements and tactics you have opted to avoid such incidents in the future.

9. Reviews

Once a final follow-up on the incident report is made, the next phase is reviewing. In this step, the supervisor or manager ensures the implementation of corrective actions against the report. The goal of the review is to prevent the recurrence of the incident and create immediate action plans. While reviewing incident reports, a reviewer should consider the following things:

10. SBAR

SBAR abbreviates Situation, Background, Assessment, and Recommendations. The reporting person’s supervisor at the time of the incident typically performs SBAR. SBAR attempts to capture more structured information about the incident, what happened, pre-conditions leading to the incident, information about the patient or staff, if involved, a first assessment of what caused the incident, and recommendations for follow-up or corrective actions.

11. Risk Scoring

A risk score is a calculated number that reflects the severity of risk due to some factors. We compute risk scores as a factor of probability and impact. It is common in the industry to use a 5×5 risk scoring matrix. But there are other methods too, and sometimes the scoring changes based on the type and nature of the incident.

12. Investigation Information

An investigator or an investigation team needs to go through all the supporting evidence to analyze the incident. The incident supporting comes in different forms, such as photos, CCTV footage, and witness statements. It is essential to verify the supporting evidence during an investigation. Information investigation often leads to:

13. Root Cause Analysis

Root cause analysis is a problem-solving method used to identify the root cause of the problem. The typical output of the RCA step is a set of contributing factors that then indicate systemic issues that may be addressed together by policy or process changes.

Standard RCA tools used in the industry include the Five Why method, Ishikawa, or the Fishbone Analysis. Some cases use more advanced techniques like the Swiss cheese model or PRISMA.

14. Contributing Factors

Contributing factors are those factors that influenced a single event or multiple events to cause an incident. If contributing factors are accelerated, it will affect the severity of the consequences. Therefore, with the knowledge of contributing factors, management can eliminate them to prevent similar incidents from occurring in the future.


QUASR implements a form of the
London Protocol for capturing these factors.

15. Executive Summary

The compelling executive summary is the final step in reporting incidents. It is a short document produced for management purposes. It summarizes a more extended report so that readers can quickly become acquainted with the material. Management can get a crisp reading of the incident from the executive summaries without reading the entire report.

Benefits of Hospital Incident Reporting

Through healthcare data analysis, setting the correct key performance indicators in your organization becomes simpler. Here are some vital benefits that you can gain from reporting.

1. Preventive Measures

 

One of the most powerful elements of an incident report is streamlining historical and current data to spot potential incidents in advance. Using predictive analysis, healthcare facilities can improve the quality of patient care and reduce workplace mishaps. Around 60% of healthcare leaders have confirmed that adopting predictive analytics has improved their efficiency considerably.

 

2. Disease Monitoring

 

Disease monitoring is one aspect of the first predictive analytics. With the incident reports, healthcare organizations can monitor potential disease outbreaks by using past and present metrics. 

 

During COVID-19, many hospitals have struggled to prevent disease outbreaks on their premises. But, the organizations that have insightful data with them may have managed the pandemic outbreak a lot easier.

3. Cost Reduction

 

Reporting can also make healthcare operations more economically effective. By gathering and analyzing incident data daily, hospitals’ can keep themselves out of legal troubles. A comprehensive medical error study compared 17 Southeastern Asian countries’ medical and examined how poor reporting increases the financial burden on healthcare facilities.

 

4. Enhanced Patient Safety

 

Improving patient safety is the ultimate goal of incident reporting. From enhancing safety standards to reducing medical errors, incident reporting helps create a sustainable environment for your patients. Eventually, when your hospital offers high-quality patient care, it will build a brand of goodwill.

Healthcare Incident Reporting Challenges

Healthcare incident reporting has various managerial and safety-related benefits. To create a result-driven incident report, you have to cross the next hurdles also:

1. Paper-based Reporting

 

In this technology era, many healthcare organizations still rely upon traditional paper-based reporting. Paper-based reporting is a manual approach where the incident details are recorded and managed using paper and often hand-written reports.

 

Paper-based reporting has numerous disadvantages, including low-quality data, limited flexibility, costly process, error-prone, time-consuming, and more. Get started digitizing your incident data by downloading our Excel-based Incident Reporting Template and quickly replace paper-based reporting. We even have a post explaining the template and how you can benefit from it.

2. Underreporting

The problem of underreporting is widespread in the healthcare industry. Common causes of underreporting include:

1) Lack of awareness about when and what to report.

2) Fear of repercussions from colleagues or seniors.

The reason behind underreporting might vary, but no one can deny that it is the biggest reporting challenge. We had written a detailed article on our assessment of under-reporting in our blog.

According to the
Agency for Healthcare Research and Quality, all healthcare facilities should offer a simple and anonymous reporting way to their staff. QUASR has built-in features to encourage reporting in a pseudo-anonymous manner encouraging staff to file a report without fear.

3. Busy Schedule

 

The busiest hospital personnel, nurses, and doctors are mainly responsible for filing incident reports. Due to their busy and often overworked schedule, they sometimes fail to report incidents. A solution must factor in this constraint at the time of design and implementation to ensure all incidents are recorded in a timely fashion without over-burdening the staff.

Conclusion

After understanding the purpose, benefits, and challenges of incident reporting in healthcare, it is clear that reporting is essential for medical facilities. Whether you wish to improve patient safety or reduce workplace mishaps, incident reporting can serve multiple purposes. But, compiling, reviewing, and investigating incidents in a timely and unbiased fashion isn’t a simple task. 

 

You require an automatic incident reporting system to manage hundreds of incidents at any given time. We can say that QUASR has practical tools to help you create track-analyze incident reports. QUASR is easy to use and access, which allows fast and accurate incident reporting. 


We have various elements in our software for resilient healthcare incident reporting ensuring all the best practices. To better understand what QUASR can do for you,
book a free demo today

 

Also, please stay connected with us as we will be covering more topics related to digitalized incident reporting.


Meanwhile, feel free to
contact us for further information!

Under-reporting Patient Safety Incidents: A Real Problem

Hak Yek Tan

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 organizations in today’s day and age where an employee is penalized 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. Organizations 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 organizations 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 organization 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 digitalized. 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 realize 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, organizations 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 organization 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 user interface 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
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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 Premium version. Even amidst our customers and prospects, we understand Lite is a little too simple for their process because they have had a computerized 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 flavor 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 an automated workflow

QUASR Basic is Lite with a workflow. It does not have all Premium version features and will probably remain that way for more time. BASIC and Premium target different types of organizations.

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 linearizing sequence of events in the incident lifecycle is what we call the “workflow”.

There’s more to QUASR Basic compared to QUASR Lite

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 to the incidents to a predetermined 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 organization.

QUASR Basic vs QUASR Premium

Lastly, as I mentioned, BASIC is Lite with automated workflow.

 

But how does Basic compare to Premium?


Premium
targets a group of institutions as opposed to independent hospitals or providers. A group has 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, customization provisions in Premium that aren’t available in Basic.

For more information, check our pricing page, and it’d be able to give you even more clarity on both these versions and options.