Each year, clinical staff working in the Perioperative Suites at BC Children’s hospital report upwards of 500 safety events in BC PSLS.  A significant number, but Warren Hill, the Quality & Safety Leader on the Unit, believed it wasn’t the full “safety” picture, and began to explore some of the most common barriers to safety event reporting.  

He found through a literature review that the most common barriers to safety event reporting among healthcare staff are:

• “too busy” to fill out patient safety/incident report forms
• fear of repercussion/punishment from managers or colleagues
• lack of follow-up when a safety event is reported – reports go into a “black hole”

Warren shared with BC PSLS staff, “When I coached a few staff members through the process of reporting a safety event into BC PSLS they would start a report and get bogged down in the drop-down boxes and pick lists.  They developed “form fatigue” as I like to call it.  They would often tell me the form was too long and they were too busy to make an incident report and would do so at the end of the day, but most of the time this would not happen.  So, I went to work dissecting the current reporting form with the intention of creating something simpler for the Perioperative staff.”

Warren and the BC PSLS staff went to work designing a new ‘simplified’ form for Perioperative Suites, using a version of the BC Patient Safety & Learning System, then trialing it with surgeons, anesthetists, nurses, managers and allied health.  The new form had fewer but more specific questions, allowing reporters to focus on What happened? and What should have happened?  A free text field allowed Reporters to share their comments in their own words with the option of requesting to be contacted by a Quality & Safety Leader after submitting an event, or after the follow-up was done.

After several weeks, the trial was considered a success!  Feedback from Unit staff showed that the brevity of the new simplified form was a strong motivator for reporting safety events in BC PSLS.  Physicians were particularly impressed and reporting rates among this group increased by one-third in the first 60 days post- implementation.  In addition, anonymous reporting decreased with two-thirds of all reporters requesting contact from a Quality & Safety Leader once the event was followed up, “closing the loop,” and improving patient safety on the Unit.

It should be mentioned that there was some additional workload on the part of the BC PSLS Handler.  Since the Reporter no longer classified the incident category, Warren was required to complete that portion on follow-up.  But, there was also an upside – event classification was much more consistent.

Excitement about the new simplified form in Perioperative Suites has spread throughout BC Children’s!  A new ‘simplified’ form is now being trialed in Emergency.

If you are interested in hearing more about this important work at BC Children’s Hospital & Health Centre, please contact Denise Hudson dhudson@phsa.ca