How Reporting Events Can Impact Patient Safety and Improve Healthcare

The goals of reporting events that impact patient safety are twofold: to avoid causing harm to patients and to improve healthcare. Sharing this information can inspire tremendous change.

Positive Change

When young children learn about personal safety, they are encouraged to speak up if they see something or someone that seems suspicious. The hope is that by confiding in a trusted adult, one of several outcomes will transpire: a conversation will lead to greater understanding; a fear can be alleviated; or a dangerous situation can be avoided.

This same concept applies to medical event reporting. The goals of reporting events that impact patient safety are twofold: to avoid causing harm to patients and to improve healthcare. As the Patient Safety Authority explains, “reporting isn’t about assigning blame, but about explaining what went wrong so that next time, and every time thereafter, it goes right.”

While it is true that some healthcare professionals may be reluctant to share their stories in fear, they will be held responsible for whatever mishaps occurred, it is also true that sharing this information can inspire tremendous change that leads to improved patient safety and care, the essential work of all healthcare providers.

Event Reporting that Leads to Change: Three Examples

#1 Being Prepared for Allergies

A patient required surgery to repair a hernia. While preparing for the procedure, the patient disclosed that he had an adhesive allergy. The surgical team opted to use paper tape. The hernia repair was successful, but the patient sustained major skin tears when the nurse anesthetist removed the tape.

A team formed to review this incident. Their discussion revealed several opportunities for improvement, most notably the creation of a kit for patients with severe skin allergies that included hypoallergenic products. They proceeded to make this kit available on the surgical floors and throughout the hospital. Furthermore, they shared this story with other hospital systems in the area so that they could learn from this incident and take steps not only to prevent it from occurring again but also to improve the safety of all patients with adhesive allergies.

#2 Avoiding Medication Mixups

24 weeks pregnant, a woman was having contractions. Having suffered two prior miscarriages, she had a cervical cerclage, a treatment that involves closing the cervix with stiches to prevent preterm birth. Using the electronic medical record, the nurse erroneously ordered and administered Prostin for the patient, which is used to induce contractions, instead of Prometrium, which is used to prevent premature labor. Luckily, another nurse recognized the error, and they were able to stop the Prostin and stop premature labor from occurring.

As the team reviewed the incident, they recognized that there were several human factors that contributed to the error: two medications that both begin with the same three letters, these two medicines were both used for pregnancy and delivery, and a pharmacist who did not have complete patient information and therefore did not recognize that the Prostin was in conflict with another medication the patient was taking. They ultimately made the decision to remove Prostin, a rarely used medication, from the drop-down menu on the electronic medical record. Additionally, several discussions ensued to raise awareness of the importance of providing complete information of the medications a patient is taking.

#3 Breaking Barriers at the Blood Bank

When an emergency department needed blood, it contacted the blood bank according to protocol. Impatient, a doctor went to find out why it was taking so long. Unfortunately, there was a breakdown in communication, as the personnel who helped transfer the blood were busy with other emergencies. In fact, they even received a message that the blood was no longer needed.

While a calamity was avoided, this incident made it clear that a better action plan was needed. A team of healthcare providers, nurses, lab technicians, blood bank staff, and hospital administrators investigated the breakdown to identify the problem and propose a better plan. A combination of staffing shortages and technological issues proved to be at the root of this particular event, prompting the team to develop a response that utilized the paging system. This way, they could broadcast the alert, so that all staff members would receive the information. They also created a revised telephone protocol.

When Barack Obama declared that “Change is never easy, but always possible,” he very well could have been referring to healthcare. Event reporting is one tool that encourages changes that improve patient care and promote safety.

At The Eisen Law Firm, we have handled cases that resulted in changed policy and procedures in hospitals to improve patient safety. We have been directly responsible for improved patient safety protocols due to medical errors that could have been prevented. Event reporting is one tool that hospitals should use to improve safety, but sadly, not every event gets the attention and resultant change that is needed.

If you or someone you love has a story to share, please don’t hesitate to contact our experienced Cleveland malpractice lawyers to discuss your options, not only for legal recourse and for obtaining the compensation you deserve, but also for helping to change healthcare for the better. To schedule your free consultation, call 216-687-0900 or contact us online today.