Among the many responsibilities expected of the governing body of a health care organization, few are as important as establishing a system for the identification, reporting, analysis and prevention of adverse incidents or events.

Having this system in place as an integral tool in creating and maintaining a safe environment was underscored in a recent presentation from U.S. Airways Flight 1549 co-pilot Jeff Skiles at the 2012 ASCA annual meeting in Dallas. This was the flight that successfully landed in the Hudson River in January 2009 after both engines were disabled after encountering a flock of birds. Mr. Skiles credited the successful outcome in large part to the culture of safety created by the airline industry.

That culture has been created by deliberate actions taken by the airline industry to ensure that all employees are involved in reporting all variations from normal operating routines. This includes pilots, flight crews, schedulers, ground and air control staff and maintenance.

These reports are then analyzed to identify causal factors and areas for improvement to prevent the likelihood of such incidents or events in the future. It is this ongoing analysis of all events, even the “near misses,” along with training and drills, that help to create this culture of safety.

There are obvious correlations between the airline industry and the health care industry where opportunities to create a culture of safety are concerned. However, there is also evidence that the health care industry has perhaps not fully embraced the shift in culture that the airline industry has embraced when it comes to adverse incident or event reporting.

In a 2005 study, “Silence Kills: The Seven Crucial Conversations for Healthcare”, the investigators reported:

  • 84 percent of doctors have seen coworkers take shortcuts that endanger patients
  • 88 percent of doctors work with people who show poor clinical judgment
  • Fewer than 10 percent of physicians, nurses, and other clinical staff directly confront their colleagues about their concerns.

The authors suggest that safety tools and checklists are not enough to prevent adverse incidents or events and perhaps save lives. A 2012 report by CMS-Medicare on hospital incident reporting systems concluded that such systems capture only about 14 percent of patient harm events. One is left to wonder that if actual patient harm events are being under reported, how often are “near misses” or other variances from the standard of care being reported?

The Accreditation Association for Ambulatory Health Care (AAAHC) has provided a guide for health care organizations to develop a meaningful adverse incident or event program. Chapter 2 in the AAAHC Accreditation Handbook is devoted to Governance, and Standard B addresses the governing body as fully and legally responsible for the performance of the organization, including the establishment of an adverse incident or event system. The elements of this system should include:

1. The definition of an adverse incident or event that includes:

a) an unexpected occurrence during a health care encounter involving a patient death or serious physical or psychological injury or illness not related to the natural course of the patient’s illness or underlying condition. For example, a thermal injury from incorrect placement of a piece of equipment.
b) any process variation for which a recurrence carries a significant chance of a serious adverse outcome. For example, the surgeon provides an implantable device “for just this one case” that normally would have been sourced by the surgery center and it turns out to be the wrong item.
c) breaches in medical care, administrative procedures or other events resulting in an outcome that is not the standard of care or acceptable risk. For example, submitting an incorrect claim form to CMS.
d) circumstances or events that could have resulted in an adverse event. For example, two patients with the same name being scheduled for surgery on the same day.

2. A review of the frequency of occurrences, the severity of outcome, and a review of all reportable events to identify trends or patterns.

3. An analysis of each report to identify the basic causal factors that underlie the variation in performance and identify potential improvements in processes of systems.

4. A reporting process of adverse incidents or events through established channels with the organization, and that all employees and medical staff are made aware of at the time of hire or at the time
of initial appointment. Documentation of this orientation and training in the adverse incident or event reporting system should be maintained in the individual’s personnel or credential file. The system should also provide direction as to reporting requirements to external agencies in accordance with local, state, and federal laws and regulations.

5. An action plan is developed that identifies strategies for reducing or eliminating the risk of similar incidents or events occurring in the future.

Having an adverse incident or report system such as this in place will not STREAMLINER guarantee a culture of safety; but it will provide the health care organization with an important tool in establishing that environment.

RAY GRUNDMAN has been involved in ambulatory health care for over 30 years in a variety of roles, as a clinician, educator, administrator and consultant, practicing as a board certified Family Nurse Practitioner, medical group practice administrator, and founder and Executive Director of several surgery centers. He is a Board Certified Family Nurse Practitioner and a Board Certified Surgery Center Administrator. Ray is also a surveyor for AAAHC.