Learning from no-harm incidents

You may have heard that PSLS receives over 400 incident reports each day from health care providers across the province.

When this statistic is shared, we often clarify that the majority of these incidents do not result in patient harm.

Whew! That’s good news.

But hold on a second…that’s still a lot of safety incidents!

While it’s reassuring to learn that most patients are not harmed while receiving care, no-harm incidents do impact our health care system. They affect the quality of the patient experience and introduce unnecessary risk into the health care system.

So, what can be done?

To help answer this question, we’re excited to share a stellar example from Kelowna General Hospital in Interior Health.

A harmless tale?

Earlier this year, a patient was taken by a porter from an inpatient ward to medical imaging for an x-ray. The porter was informed by the ward that the patient was to go to a clinic after the x-ray was completed, and a green tag was placed on the chart. The tag was a visual indicator that the patient was to go to the clinic after the test.

Instead, the patient was returned to the ward by a different porter. Upon discovering that the patient had been returned, a third porter was called to take the patient to the clinic. As a result, the clinic was kept waiting and their appointment schedule for the day was impacted, and the patient’s discharge was delayed.

Unnecessary delay + poor use of resources + inefficiencies = frustration.

Investigation and follow-up

The issue was promptly reported in PSLS by Lori Anthony, Patient Care Coordinator, 2 South (Cardiology).

“My job is access and flow”, says Lori. “If a patient’s discharge is delayed, it not only affects that patient but also impacts the patient who may be in the community waiting for a bed.”

In addition to submitting PSLS reports, Lori also follows up incidents reported by others in her area. She reviews incidents two to three times per week, conducts investigations, and closes the loop by connecting with reporters to let them know her findings. If an incident offers an opportunity for wider learning, Lori includes it in her weekly email updates to the team or posts it on the department’s Lean Improvement board.

“I think PSLS reports are important because they start a conversation,” adds Lori.

Recognizing that this particular incident involved porters, Lori assigned Taryn McGregor, Manager, Central Functions, Porters & Morgue, to follow up.

“I always read PSLS reports the day they come in,” says Taryn. “If I’m really busy I’ll schedule time to review and investigate within a few days. In this case, I had a chance to review immediately and I was lucky because the porter I needed to talk to was still on shift.”

Taryn met with the porters and learned that the porter who brought the patient back to the unit in error was not the porter who had taken him to medical imaging. The porter who brought him back was relatively new to the patient porter role and was not aware of the meaning of the green flag on the patient’s chart.

To address the immediate learning need, Taryn had a senior porter show the new porter the green tags, what they meant, and what to look for. She noted in her summary of findings in PSLS, “As we have multiple porters in the building at any given time, there is no guarantee that the porter who picked a patient up for a medical imaging exam will be the same porter who brings them back”.

Recognizing the problem as symptomatic of a larger system issue, Taryn added the green tag process onto the new hire orientation checklist to ensure it is reviewed with every new hire, sent an email out to all porters to ensure they knew what the green tag was, and encouraged them to come and speak to her or to a fellow porter if they didn’t understand the process or wanted to review the procedure. She also flagged the topic for discussion during the team’s regular huddles.

Investigation was completed, actions taken and documented, feedback sent, and the incident given Final Approval status in PSLS within three hours of the report being submitted.

Way to go, Lori, Taryn, and their teams!

Patient safety and waste reduction

Patient safety is a serious issue all over the world.

In fact, the World Health Organization declared September 17, 2019 as the first World Patient Safety Day and launched a global campaign to create awareness and urge people to show their commitment to making health care safer. 

According to the WHO’s 10 Facts on Patient Safety, the risk of dying due to a preventable medical accident while receiving health care is estimated to be one in three hundred, compared to a one in three million risk of dying while travelling by airplane.

In a recent news item, Chris Power, CEO of the Canadian Patient Safety Institute, noted that at 28,000 deaths per year, patient harm ranks third in mortality in Canada after cancer and heart disease.

With statistics like these, it makes sense to focus our efforts on preventing serious harm.

But it’s also worth considering the issue of health care waste.

In the Institute for Healthcare Improvement’s recently published Call to Action: Reduce Waste in the US Health Care System, waste is defined as “resources expended in services, money, time, and/or personnel that do not add value for the patient, family, or community.”

Within the report, IHI president and CEO Derek Feeley states that “Waste is endemic in health care. And it’s not just money that’s being wasted. The most precious resources — the workforce’s time, spirit, and joy — are being unnecessarily drained by wasteful processes every day.”

While no-harm incidents do not result in injury, they do contribute to health care waste.

When incidents and near misses are reported promptly into PSLS and followed up while those involved are still available, they have a greater chance of being resolved quickly and efficiently—potentially preventing recurrence and reducing waste.

Safety culture

Leaders like Lori and Taryn, who demonstrate the value of reporting by following up and taking action quickly, not only help reduce health care waste, but help foster a reporting culture. This contributes to a culture of safety that is so important to staff and patients alike.

“It may seem like a simple thing, in which no one was hurt”, notes Dr. Devin Harris, Executive Medical Director, Quality and Patient Safety, Interior Health, and newly announced Chair of the BC Patient Safety & Quality Council. “However, the upstream work to build a safety culture will have impact downstream on communication, teamwork, workplace health and safety, efficiency, morale, and finally – patient outcomes.  This is a great example to highlight.”

Kudos to everyone involved in reporting and addressing this issue!

Do you have an example of a no-harm incident with a beneficial result? Please comment below or email ksteger@phsa.ca.