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I report

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Web-based incident reporting

Publicado en: Atención sanitaria
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I report

  1. 1. Hossam Elamir, MSc.HCM, TQMD, MBBCh Quality & Accreditation Office, MKH Institute of Leadership, RCSI Ahmad Mufreh, B.M., B. Ch Department of Surgery, ADH
  2. 2. “To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.” Sir Liam Donaldson
  3. 3. The report carried 4 core messages:  The magnitude of harm that results from medical errors is great  Errors result largely from systems failures, not people failures  Voluntary and mandatory reporting programs are needed
  4. 4. Martin A Makary, and Michael Daniel BMJ 2016;353:bmj.i2139
  5. 5. Leape, MD
  6. 6.  freedom from accidental or preventable injuries produced by medical care Spath, P. (2009). Introduction to Healthcare Quality Management (Chicago, IL, USA: Health Administration Press)
  7. 7.  Reporting of patient safety event is universal in healthcare and a backbone of efforts to detect patient safety issues and quality problems.(1,2)  Barriers to reporting include lack of feedback and fear of personal consequences.(3,4)
  8. 8.  AHRQ stated that effective event reporting system should have four key elements, among which are protection of the reporter privacy, providing easy accessibility to the reporting system, and timely dissemination of outcomes and feedbacks.(1)
  9. 9.  In the 750+ bedded general hospital; which is staffed with more than 3000 employees; the number of reported incidents was 50-80 reports per month.  Majority of reporters are nurses (85 %), while doctors are the least reporting staff.
  10. 10.  Most of the reported incidents are of the “no harm errors” type. Near misses (good catch) and harmful incidents are usually not reported  We distributed 35 “incident collection boxes” allover the hospital, yet, some locations are still not covered.
  11. 11.  We interviewed 200 staff; equally representing doctors, nurses, technicians and administrators; to identify the causes of underreporting.  Fear of punitive action, lack of feedback and limited access to the manual reporting form were the most common discouraging causes for not to report.
  12. 12.  Not easily Accessible  Environmentally unfriendly (Papers, ink)  Time & Effort to collect  Redundancy in efforts (Data Entry by the nurses instead of the reporter)  No Feedback due to anonymous reporting and/or overwhelming workload; If feedback given, it will be in the last stage.
  13. 13.  Opportunity for improvement  Private Public Partnership  Multidisciplinary team:  Clinician as a reporter  Quality Doctor as a manager  Senior Programmer
  14. 14. User friendly Accessible Anonymous & Confidential Secure, HIPPA compliant Feedbacks the reporter at different stages Instant Notification Permits Easy StatisticalAnalysis and Exports Data Saves History of Reports Customizable Affordable IntelligentAnalysis Framework
  15. 15. User friendly Accessible Anonymous & Confidential Secure, HIPPA compliant Feedbacks the reporter at different stages Instant Notification Permits Easy StatisticalAnalysis and Exports Data Saves History of Reports Customizable Affordable IntelligentAnalysis Framework Images and Movies can be attached too!
  16. 16. YAMCOLLC
  17. 17. 1. AHRQ. Voluntary Patient Safety Event Reporting (Incident Reporting) | AHRQ Patient Safety Network [Internet]. 2014 [cited 2016 Apr 10]. Available from: eportingincidentreporting 2. Lawton R, Parker D. Barriers to incident reporting in a healthcare system. Qual Saf Health Care. 2002;11(1):15–8. 3. Noble DJ, Pronovost PJ. Underreporting of patient safety incidents reduces health care’s ability to quantify and accurately measure harm reduction. J Patient Saf. 2010 Dec;6(4):247–50. 4. Mahajan RP. Critical incident reporting and learning. Br J Anaesth. 2010;105(1):69–75.
  18. 18. Dr.HossamElamir 0096565198442 Linkedin: Dr.AhmadMufreh 0096569999126 Linkedin: