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Redesigning the Fall Incident Report

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Redesigning the Fall Incident Report A SAFETY INITIATIVE REDESIGNING THE FALL INCIDENT REPORT Joanne Elkins, MSN, RN, CPHQ, Lula Williams, MN, RN, CPHQ, Andrea M. Spehar, MS, DVM, MPH, Patricia A. Quigley, PhD, ARNP, CRRN, Tamala Gulley, MSCE, and Josefina Perez-Marrero, PhD Representing up to 89% of all reported adverse clinical incidents, falls are costly in both human and financial terms. Here’s how VISN 8 transformed their fall reporting process so that it could be used to drive system changes that would prevent falls. here seems to be a gen- tial sentinel events, with the goal of reported clinical incidents and are eral consensus among cli- improving the quality and safety of the most costly category in both nicians in this country patient care.1,2 In order for the RCA human and financial terms.7 T that most adverse health process to be successful in improv- In this article, we’ll discuss the care events result from system er- ing systems, investigators must VISN 8 incident reporting system rors. To correct such errors, in Feb- gather accurate, timely, and rele- and the process through which it ruary 1999, the VA established the vant data regarding clinical events was redesigned. We’ll outline the National Center for Patient Safety that are both ubiquitous and under- barriers we faced in implementing (NCPS), which implemented the reported.3–6 a VISN-wide incident report form process of root cause analysis In the fall of 1999, VA medical for patient falls and review the (RCA) to investigate and review center and clinic administrators types of data that must be gathered findings from all actual and poten- throughout Veterans Integrated in order for patterns, trends, and Service Network (VISN) 8 ac- root causes of such falls to be ana- knowledged that the incident re- lyzed successfully. Ms. Elkins is a quality systems coordinator and Ms. Williams is a utilization manager, both at the Bay porting forms then in use were very Pines VA Medical Center, Bay Pines, FL. Dr. Spehar is limited in permitting the collection IDENTIFYING THE NEED a project manager and Dr. Quigley is an associate of pertinent data. These leaders FOR CHANGE director of the clinical division at the Veterans Inte- grated Service Network 8 Patient Safety Center of In- made a commitment to standardize The VHA’s increasing emphasis on quiry, both at the James A. Haley Veterans’ Hospital, incident reporting procedures for improving patient safety and the Tampa, FL. Ms. Gulley is an industrial engineer and, adverse events—in particular, pa- mounting national focus on medical at the time of submission, Dr. Perez-Marrero was a research assistant, both at the Bay Pines VA Medical tient falls, which represent be- errors, typified by the 1999 Insti- Center. tween 25% and 89% of all such tute of Medicine report on patient Continued on page 33 MARCH 2004 • FEDERAL PRACTITIONER • 29 REPORTING FALLS Continued from page 29 safety,3 provided an ideal backdrop awareness of falls and engenders a do-check-act” (PDCA) cycle and for a VISN-wide redesign of the sys- learning culture among staff, ensur- Lewin’s planned change and tem for reporting adverse inci- ing that action will be taken to min- force field analysis.11 For the pur- dents. After being awarded one of imize the incidence of falls in the poses of this project, however, four VHA grants to create a Patient future.7 Used correctly, incident re- our team selected Jacob’s real Safety Center of Inquiry, VISN 8 es- ports aren’t merely “paper compli- time strategic change model, in tablished such a center in 1999, ance,” but beneficial tools for which large numbers of people under the direction of Dr. Audrey communication.9 work together over a few days to Nelson. As part of this effort, a pa- Unfortunately, the generic VHA bring about character and per- tient safety improvement (PSI) incident report form widely used in formance changes in a very large board was created, consisting of 1999 (form VA 10-2633) had a num- organization.11 According to this risk, patient safety, and quality ber of deficiencies that did not fa- model, resistance to change in managers from each VISN 8 med- cilitate the collection of complete, large organizations is overcome ical center. The initial focus of the relevant, useful fall-related infor- only when there is agreement PSI board was developing a stan- mation. Such deficiencies were among a critical mass of people dardized system of reporting and highlighted in the standards issued on: (1) dissatisfaction with the managing data about patient falls. by the Joint Commission on Ac- status quo, (2) a clearly articu- The board concentrated on falls be- creditation of Healthcare Organiza- lated vision of a possible future, cause of the prevalence, cost, and tions in 1995 and revised in 2001.5 and (3) concrete steps to be taken impact of these incidents on quality Ultimately, PSI board members to realize that vision.8 of life.7 would concur that incident report To help a critical mass of people Patient falls tend to be underre- forms should include objective accept dissatisfaction with the sta- ported by hospital and nursing terms and succinctly document any tus quo, PSI leadership planned a home staff for a number of rea- action taken to provide care at the workshop to address VISN issues sons. For one, there may be some scene. We would further determine related to incident reporting and confusion among staff about which that if the collected data were in an the patient safety improvement sys- falls to report. A noninjurious fall, electronic form that could be inte- tem. As a preface to this workshop, for example, may go unreported grated into the existing computer- they conducted a telephone survey because it’s believed to be insignifi- ized patient record system (CPRS), of PSI board members to obtain cant. Another factor that may in- it would enable VA providers and their input on reporting, barriers to hibit reporting is the belief that risk and patient safety managers to data collection, quality and use of management and other administra- track patients who have fallen and data, and the components of an tive staff don’t act on incident re- follow up on their treatment inter- ideal patient safety improvement ports, so the reports are simply ventions. We would discover that in system. Board members consis- unnecessary paperwork. Finally, order to make the system changes tently identified the lack of a rele- staff may be hesitant to report a pa- necessary to improve patient and vant, useful, and usable reporting tient fall because they fear disciplin- environmental safety, we would system as one of the most signifi- ary action from supervisors.7 need to implement a standardized, cant barriers to gathering data nec- But incident reporting, as a computerized, incident reporting essary to manage risk in their process intended to detect and system (SCIRS). Our undertakings facilities. characterize patient falls, is an im- would bring us back to the funda- Survey results served as the portant component of any risk mentals of risk management: devel- framework for the first meeting’s management program aimed at fall oping good documentation and agenda and were presented to par- reduction. According to Guido and educating staff members on inci- ticipants at the PSI board training colleagues, such forms were “de- dent reporting policy and proce- session. Faculty, which included signed to be part of the overall risk dure.10 leaders from risk and patient management or quality assurance safety management, quality im- effort of any health-oriented institu- PLANNING FOR CHANGE provement, executive manage- tion.”8 Ideally, incident reporting Traditional models of planned ment, behavioral sciences, and and subsequent RCA creates an change include Shewhart’s “plan- information management, pro- MARCH 2004 • FEDERAL PRACTITIONER • 33 REPORTING FALLS vided information and facilitated such as a fall or a medication is pertinent and usable for system discussion groups regarding the im- error, was not collected. change, integrate injury-related data portance of incident report data, Participants voiced their frustra- into the RCA process as the founda- barriers to reporting adverse tion in devising a form or method tion for systems analysis, examine events, the necessity of collecting for collecting data that could be VISN-wide patterns and trends sur- data in order to examine practice used to drive system changes to rounding patient falls, and increase and process, and use of computer prevent falls. They also expressed a the completeness of incident report technologies to facilitate documen- strong interest in comparing data elements. Participants also deter- tation and data collection and and sharing learning experiences mined that it would be necessary to analysis. The discussions served as with other facilities in the VISN. As develop a new report card to com- a basis for building a consensus participants discussed their forms pare fall-related data within VISN 8. around the need for a better inci- and processes, they repeatedly re- Ray has proposed specific dent reporting system. ported that recognition of a fall was performance indicators for effec- The SCIRS emerged as a clearly just one barrier to effective patient tive systems including consumer- articulated vision of a possible fu- safety improvement. A second bar- centeredness, accountable report- ture. The critical mass of people rier was the multistep reporting ing, thorough fact finding, prompt participating in this training ses- process, through which informa- identification and implementation sion agreed that an SCIRS would tion transfer to risk management of corrective actions, fairness, and facilitate the implementation of frequently was delayed. cost-effectiveness.12 Our objectives system changes needed to im- Participants agreed that it would mirrored those of Ray.
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