Precision is integral to patient safety, yet hospitals' standard manual approach of reporting patient safety events has been shown to paint a less-than-accurate picture of the harm patients experience on a regular basis.
When hospitals rely on manual reporting of safety events, they are made aware of less than 5 percent of all-cause harm. Before delving further into how hospitals' current reporting falls short, it is first helpful to understand the difference between medical errors and all-cause harm.
To distinguish the two concepts, Becker's Healthcare caught up with Valere Lemon, RN, MBA, a senior subject matter expert for Salt Lake City-based Health Catalyst who has also worked as a pediatric hematology/oncology nurse at two children's hospitals.
Note: Responses have been edited lightly for length and clarity.
Question: What is the best way to distinguish medical errors from harm?
Valere Lemon: Errors are still harm; they really aren't different from one another. In as simple terms as possible, a harm results from a prescribed procedure, process or medication administered incorrectly or due to the patient's unintended response to that medical care — it doesn't mean it was an intentional error. For example, a nurse could give a medication to the wrong patient — that's considered an error.
But a lot of clinicians don't frequently think of less overt types of harm that happen to patients. For example, say a nurse gives the right dose of insulin to the right patient, but the patient still experiences an unintended consequence from that insulin. The nurse then gives the patient orange juice to bring his or her blood sugar back up and monitors the patient to ensure everything goes well for the rest of his or her stay. A lot of clinicians wouldn't consider that patient harm, but it is. The patient didn't tolerate a medication or procedure. When a patient experiences a negative consequence from care received in the hospital, that's still harm. Even if we didn't do anything wrong in providing care to them, we can still learn from that.
Q: Is this distinction widely understood in hospitals among clinical staff?
VL: To quality and risk managers, I would say the distinction between harm and medical errors is pretty well understood, although there's even confusion among those populations because their focus is on reportable events like pressure ulcers, falls, CLABSIs and CAUTIs. But other clinicians who you expect to report these types of events would rarely think of something like I described with the insulin example as harm, and they wouldn't report it. They would not think to report it unless their patient had a serious event where they became unconscious and needed resuscitation. If a patient simply needed orange juice to remedy an unintended consequence of treatment, it likely wouldn't be reported in a voluntary reporting system.
Q: Why is the distinction not widely understood?
VL: Not a lot of time is spent in the medical profession teaching bedside clinicians the difference between the two. Even in medical schools and nursing schools, we don't spend a lot of time talking about reporting events — it's all about patient care. We encourage staff to report anything they want to report that they think was unsafe for the patient, but telling them to report every time your patient has a hyperglycemic event just doesn't happen. If systems did report all such events, it could create an overreporting problem, including a lot of false positives in the documentation.
Q: Do hospitals have the right tools today to identify and report patient harm?
VL: All hospitals have voluntary reporting systems, so every person in the organization down to food and nutrition has access to report something they feel is a safety event. Even though they have access to a reporting tool, creating an organizational culture focused on patient safety is an equally, if not a more, important tool. A lot of people don't feel comfortable reporting events they identify because they are worried about getting in trouble or getting their friend in trouble. Or, they might not understand they need to report it. Or, they might not have time. Taking a few extra minutes during that day or at end of shift when they are ready to go home is not always realistic.
Q: What are some best practices organizations can enact to improve reporting and identification of patient harm?
VL: First, communication is key. Communicate with staff and make them aware that it is acceptable to report and that there will be no retaliation. Reporting about safety events will be seen as a system issue.
Second, assess the accessibility and organizational education of applications. Educate staff on what issues should be raised to the quality and risk team and assess the access of voluntary reporting applications. Most allow you to submit anonymously, so that makes it difficult for feedback, but promotes a just culture where people can report without feeling like they'll get in trouble. Reporting applications are usually web-based. There are voluntary reporting vendors available, but they don't really surveil. Those gaps are what leads to organizations needing a surveillance application, because clinicians don't understand what to report and how to identify gaps in care protocols.
Q: What are some obstacles that clinicians face in reporting patient harm?
VL: In addition to what I've mentioned so far, one other barrier is a lack of accountability. As a clinician, I would submit an incident report in my hospital and could see who it was sent to, but most of the time that was the end of it. You don't know if any action or follow-up was taken. Most often, the only ways I learned if incident reports were addressed were if someone was fired or if a policy changed on the unit due to multiple errors that kept happening.
Clinicians go to work every day and try to do the right thing, but a lot of clinicians I've heard from in my years of nursing say they don't see the need to report the event because their manager isn't going to respond to it, won't follow up or won't change anything. Ultimately, it goes back to creating a culture that emphasizes safety and accountability of managers to close the loop on all reports of harm.
Editor's note: This is part one of a two-part series. To continue the series on all-cause harm identification, reporting and improvement efforts, click here.
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