10,000 Good Catches: Increasing Safety Event Reporting In A Pediatric Health Care System

• Published in: Pediatric quality & safety 2018-03, Vol.3 (2), p.e072-e072
• Main Authors: Crandall, Kristen M., Almuhanna, Ahmed, Cady, Rebecca, Fahey, Lisbeth, Floyd, Tara Taylor, Freiburg, Debbie, Hilliard, Mary Anne, Kalburgi, Sonal, Khan, Nafis I., Patrick, DiAnthia, Pavuluri, Padmaja, Potter, Kelvin, Scafidi, Lisa, Sigman, Laura, Shah, Rahul K.
• Format: Article
• Language: English
• Subjects: Individual QI Projects from Single Institutions
• ISSN: 2472-0054; 2472-0054
• DOI: 10.1097/pq9.0000000000000072

In 2014, Children's National Health System's executive leadership team challenged the organization to double the number of voluntary safety event reports submitted over a 3-year period; the intent was to increase reliability and promote our safety culture by hardwiring employee event reporting. Following a Donabedian quality improvement framework of structure, process, and outcomes, a multidisciplinary team was formed and areas for improvement were identified. The multidisciplinary team focused on 3 major areas: the perceived ease of reporting (ie, how difficult is it to report an event?); the perceived safety of reporting (ie, will I get in trouble for reporting?); and the perceived impact of reporting (ie, does my report make a difference?) technology, making it safe to report, and how reporting makes a difference. The team developed a key driver diagram and implemented interventions designed to impact the key drivers and to increase reporting. Children's National increased the number of safety event reports from 4,668 in fiscal year 2014 to 10,971 safety event reports in fiscal year 2017. Median event report submission time was decreased by nearly 30%, anonymous reporting decreased by 69%, the number of submitting departments increased by 94%, and the number of reports submitted as "other" decreased from a baseline of 6% to 2%. Children's National Health System's focus on increasing safety event reporting resulted in increased organizational engagement and attention. This initiative served as a tangible step to improve organizational reliability and the culture of safety and is readily generalizable to other hospitals.