“Less is More”Simplified Perioperative

BC PSLS ReportingDenise Hudson, BC PSLS

Warren Hill, BCCH

The problem• Under-reporting of patient safety events in the

perioperative suites• Length of time to complete a report form• Low reporting rate by health care team members

other than Nursing• Insufficient information on form to guide follow-up

response

Aim statement

To increase reporting of hazards, near misses and patient safety events to the BC Patient Safety & Learning System by staff in the perioperative suites at BC Children’s Hospital by 10% by March 7, 2012

Proposed changes• Shorten the PSLS report form• Ask fewer questions• Eliminate some drop-down fields

(e.g. categorization of event)• Prompt for more narrative information• Clarify “near miss” and “potential for harm”

questions• Add options for feedback to reporters

Process• Met with focus groups• Drafted sample form and

vetted with group• Developed new form and

implementation plan with BC PSLS Central Office

• Communicated through email, posters, safety rounds

New report form

New report form

New report form

What we thought would happen• Decreased time for reporter to complete form• Increased number of reports from staff other than

nurses• Better understanding of follow-up needs of reporters• Clearer distinction of actual from potential patient

harm• Increased number of events reported• Increased satisfaction of staff with the safety

reporting process

What we found after 60 days• Time to complete form ~5.5 mins; 45% reduction• 33% increase in physician-generated reports• Event follow-up expectations were clarified and

helped to triage event follow-up• 93% reduction in anonymous reports• Average # of words in event description remained

almost the same (53 pre vs. 55 post)• Slightly increased handler time needed for post-

event classification• Reporting volume declined by 11%

Requests for follow-up• No (31%)• Yes - Contact me about this event as soon as

possible (4%)• Yes - Would like an update when follow-up is

complete (65%)

Preventing severe harm• New form asks the reporter if there was potential for

severe harm• Identifying the potential for severe harm helps to

prevent future actual harm• 100% of physician-generated reports using new form

described potential for severe harm relating to the incident (cf. 10% using old form)

Examples of potential harm given•Air embolus, leading to cardiovascular collapse, possible cardiac arrest, possible death•All events and procedures for child could have been on the wrong patient•If he had been unable to cough his secretions out, and I was not able to suction him in a timely manner, he could have experienced severe respiratory compromise•If screw had fallen into the open mastoid bone and not noticed, patient would have been left with a foreign object in body!•If the patient didn't have an ID bracelet on there is a potential that the wrong patient was operated on, and also there was no consent with the patient•Paralysis•Could have become hypoxic, drop in O2 saturation, delay in ability to support airway•Prolonged apnea requiring possible PICU admission and ventilation•Septic - could have become increasingly sick without notice.•Skin necrosis due to pressure in the prone position for 2.5 hours•We might have hooked up the IVs to the wrong patient, thereby infecting him(the pt, also did not have ID bands on, but that is a separate PSLS!)•We were not told in handover that the patient had allergies to penicillin. We nearly connected up the wrong IV pumps to this child.

Safety event reporting survey Sample automated reply to reporter:

Privileged & Confidential - For Quality Assurance Purposes Only.You have submitted a Patient Safety Event Report via the PHSA BC PSLS system with the following details:PSLS Event ID: XXXXXXDate of Event: 21/02/2012 Handler: Please click here to fill out a quick survey about safety event reporing in the BC Children's Perioperative Area.Thank you for your commitment to safety!By recognizing, reporting, and acting on safety hazards, events and situations, you are helping to improve the quality of care for our patients, residents, clients, and staff, and to foster a culture of safety. Your report assists in identifying and analyzing system challenges and other opportunities for improvement.For more information, please contact your immediate supervisor, using the PSLS Event ID provided.

Survey results: New form ratingCompared to the "old" PSLS report form, how would you rate the following aspects of the "new" form?

Answer OptionsMuch bette

r

Slightly

better

No chang

eWorse

Rating Averag

eN

Length of the form 24 1 0 0 1.04 25Clarity of questions

18 6 1 0 1.32 25

Usefulness of "help" and examples

15 4 2 0 1.38 21

Survey results: Less is more

96.0%

4.0%

Were the questions on the new form detailed enough to help you provide all important information?

YesNo

Survey results: Satisfaction

68.0%

32.0%

Overall, how satisfied are you with the new form?

Very satisfied

Satisfied

Not satisfied

Survey results: Comments• Love options to have follow-up or not• Shorter form will encourage reporting• Simplified form is user-friendly, quick to fill out, less

wasted effort• Clearer, more clinically-relevant questions (e.g.

degree of harm), better explanations• It is a very appropriate system with exceptional

follow-up in my experience• Keep encouraging staff other than nursing to report

Project limitations• Short window of time for comparison may not reflect

actual trends (i.e. 60 days pre- and post-implementation)

• Tested during holiday period when regular staff are often away, activity level is reduced

• Recruitment bias in survey and advertising• Pilot-tested in one area - may not necessarily be

generalized to other units/areas• Difficult to determine impact of significant quality

improvement initiative on reporting volume

Summary of findings• Reporters much prefer simplified form and options

for follow-up• Reporting from physicians has increased• More accurate distinction between actual and

potential harm (detected events at “no harm” level without false alarms)

• Simplifying form did not increase report volume• Incident follow-up is essential to success• Asking reporters how they want to be involved in

follow-up fosters commitment to safety culture

Suggested improvements• Reduce date/time questions and auto-populate fields

where possible• Consider automated email feedback to reporters

when follow-up is completed• Offer more education on safety event reporting• Standardize process for follow-up• Make information gathered more clinically relevant

and less administrative

Next steps• Revise form to incorporate feedback• Share with others to determine potential for wider

implementation• Assess follow-up pathways and address workload

for administrative data collection (if reporter doesn’t fill it out, who will?)

• Check results at regular intervals (PDSA)

Thanks!• BCCH perioperative nurses,

physicians and staff• BC PSLS Central Office Team

Annemarie TaylorMichelle PrestonInderpal Chani

• BCCH Quality and Safety Leaders