CITE THIS CONTENT: RYAN MURPHY, “EVENT REPORTING”, ACCELERATE UNIVERSITY OF UTAH HEALTH CURRICULUM, JUNE 1, 2018 (Updated August 24, 2018. AVAILABLE AT: HTTPS://UOFUHEALTH.UTAH.EDU/ACCELERATE/EXPLORE/PLAYLISTS/SAFETY/EVENT-REPORTING.PHP. https://uofuhealth.utah.edu/accelerate/explore/playlists/safety/culture-of-safety.php

ABOUT THIS LESSON Many people ask, “What am I supposed to report?” or “Does this count?” This lesson covers the basic vocabulary of patient safety event reporting to recognize and report potential safety events. Learning Objectives: identify harm and the potential for harm in a health care setting recognize events that should be reported

What is safety event reporting? Safety event reporting is a formal process for identifying anything that harms or has the potential to harm. At University of Utah Health, we report anything that harms or has the potential to harm. At University of Utah Health, we tell our employees to “report anything that harms or has the potential to harm.”

First, let’s define “harm” The Agency for Healthcare Research and Quality (AHRQ) currently defines harm as: Physical or psychological injury, inconvenience, monetary loss, and/or social impact suffered by a person. HARM IN MEDICAL CARE Harm and the potential for harm from medical care is pervasive and well-documented. Much of the safety literature has historically focused on physical harm, but the Agency for Healthcare Research and Quality (AHRQ) currently defines harm as: Physical or psychological injury, inconvenience, monetary loss, and/or social impact suffered by a person. Some harm may be the result of medical error (and therefore preventable), while some will be an inevitable consequence of medical care (nonpreventable). Recognizing harm once it occurs is usually straightforward. To create a safer environment, individuals must also focus on instances where potential for harm exists, regardless of reason or outcome. BY THE NUMBERS 4.65 injuries per 100 hospitalizations 10-12% of patients experience harm Approx. half of events are preventable SOURCE: AHRQ. Accessed online 24 August 2018 at https://psnet.ahrq.gov/primers/primer/34/adverse-events-near-misses-and-errors

AHRQ’S 3 SCENARIOS TO REPORT INCIDENTS & ADVERSE EVENTS Any event that reaches a patient, regardless of whether or not it resulted in harm, is considered an incident. If that event does result in harm, it is considered an adverse event. NEAR MISSES If an event occurs but fails to reach the patient, whether by chance or by intervention, this is defined as a near miss. UNSAFE CONDITIONS If conditions exist that are not related to a specific patient but increase the risk of an event occurring, this is considered an unsafe condition. AHRQ identifies three scenarios of concern, all of which should be reported: 1. Incidents & Adverse Events: Any event that reaches a patient, regardless of whether or not it resulted in harm, is considered an incident. If that event does result in harm, it is considered an adverse event. Imagine a hospital provider accidentally prescribes a medication meant for patient A to patient B. Once the drug reaches patient B, it is considered an incident. If patient B takes the drug and suffers some form of harm, this is considered an adverse event. 2. Near Misses: If an event occurs but fails to reach the patient, whether by chance or by intervention, this is defined as a near miss. Imagine a provider calls in a prescription to a pharmacy for an antibiotic to which a patient is allergic. If the pharmacist identifies the allergy and notifies the ordering provider to change the prescription to an alternative, this would be an example of a near miss. 3. Unsafe Conditions: If conditions exist that are not related to a specific patient but increase the risk of an event occurring, this is considered an unsafe condition. Imagine medications with similar sounding names and labels stored next to each other. Though no patient is in that scenario, this is an unsafe condition that has increased risk of harm occurring.

How do I report? Every organization has a method for reporting and responding to safety events. At U of U Health, you can submit an “RL” (Report and Learn) on Pulse: https://pulse.utah.edu/site/PatientSafety How do I report and what happens when I submit? Every organization has a method to report safety events. FOR U OF U HEALTH EVENT REPORTING | Patient safety event reports filed in RL are sent to a file manager, who is responsible for review of events for a specific unit or service. This file manager investigates and takes appropriate actions, documenting the results of the investigation and following up with the frontline reporter at the discretion of the file manager. Further details on each step of the Event Response Algorithm and other policy guidelines can be found on Pulse. FOR VAMC EVENT REPORTING | All event reports submitted at the VA are reviewed by the Patient Safety office, which works with the specific clinical area to help address system-based errors. Additionally, the Patient Safety office aggregates errors to detect any major trends, reporting directly to the facility leadership any recommendations for improvement.

What additional defenses would you add to make the system safer? DISCUSSION THINK ABOUT IT Think of a safety event you witnessed in the past. Can you identify whether it was an adverse event, near miss, or unsafe condition? Considering the same event, what systems defenses (if any) were in place to prevent the error? What additional defenses would you add to make the system safer? For more on this and other topics, explore: https://uofuhealth.utah.edu/accelerate/ If you’re an instructor, try this 2-minute in-person exercise: Have learners volunteer personal real-life examples of adverse events, near misses, and unsafe conditions either within or outside of medicine. Active participation is ideal, but could have a backup list of a number of 1-sentence scenarios and have learners identify medical error, near miss, adverse event, unsafe condition if needed.   Prior to session, have learners take a photo of a particularly safe or unsafe process or environment on their smartphone. In person, share photos and answer questions: How could (or did) human error lead to harm in your scenario? (if delving into further modules, e.g. Swiss Cheese Model, systems redesign can also ask) What systems defenses (if any) are in place to prevent error from leading to harm? What additional defenses would you add to make this system safer? CITE THIS CONTENT: RYAN MURPHY, “EVENT REPORTING”, ACCELERATE UNIVERSITY OF UTAH HEALTH CURRICULUM, JUNE 1, 2018. AVAILABLE AT: HTTPS://UOFUHEALTH.UTAH.EDU/ACCELERATE/EXPLORE/PLAYLISTS/SAFETY/EVENT-REPORTING.PHP.