A Nonpunitive, Computerized System For Improved Reporting of Medical Occurrences

Abstract

To improve the patient safety program at the Naval Hospital at Oak Harbor, the facility instituted a new computerized system of reporting errors, incorporating a nonpunitive approach. The new “Culture of Safety” led to a paradigm shift in assessing an individual’s performance, event occurrences and error reporting. Prior to the patient safety initiative, under the then-existing error reporting system, staff members at the Naval Hospital at Oak Harbor were held personally accountable and subject to discipline for errors they committed. Under the Culture of Safety program, most errors are considered preventable and attributable to systems issues. The new reporting system is used to assess systems failures, not individual performance. Staff may input errors and occurrences directly into the computerized database or submit paper reports. Although anonymous reporting is allowed, staff members are encouraged to identify themselves. Reviewers comment on the errors and occurrences reported to help identify trends and develop baselines for quality improvement activities. Ultimately, the appointed physician advisor for performance improvement summarizes what actions are needed to remediate the problem. The new system provides up-to-the-minute information for review, dissemination and action, replacing paper trails and time-consuming meetings that failed to resolve occurrences. Data collected provides feedback to department heads, allowing for monitoring, systems improvement or environmental changes. Aggregate data are tracked, trended and fully disseminated.