Patient safety challenges are exacerbated by healthcare workforce challenges. However, a workplace culture focused on measuring what goes wrong and making changes to address root causes – powered by reporting and analytics technology and encouraged by the example set by top leadership – can address these significant forces impacting care delivery. 

As healthcare workers signaled plans to leave the industry after the burnout of the COVID-19 pandemic years, the non-profit Emergency Care Research Institute said in 2022 that it was concerned about a widespread increase in patient safety risks. 

More recently, ECRI identified medication administration errors, care delays induced by drug and supply shortages, workplace violence and patient falls as healthcare’s top safety concerns in its most recent annual list of patient safety dangers. 

But by implementing data and analysis tools for patient safety and performance improvement, healthcare organizations can leverage "near-miss" data to prevent incidents that result in injury – and also reduce costs.

Today’s healthcare environment demands effective digital tools and a commitment to cultural change, according to Heidi Raines, founder and CEO of Performance Health Partners, a healthcare safety software vendor. 

"Prompt action is critical in healthcare, where timely intervention can greatly influence outcomes," she says.

We spoke with Raines about near-miss reporting, and how better analytics and a culture of data-driven leadership can improve patient safety.

Q. What about the near-miss reporting process is confusing, and how can it be improved?

A. According to Heinrich’s Law, for every safety incident with injury, 300 near misses often go unreported or underreported. This highlights a critical opportunity to prevent incidents of injury and harm within healthcare organizations.

A near miss, or what we also refer to as a "good catch" in healthcare, is an incident that nearly caused injury or harm but didn't due to timely intervention or by chance. 

The first step in refining the near-miss reporting process involves the organization clarifying what exactly constitutes a near miss. This clarity is crucial in alleviating the confusion healthcare workers often face when determining what and when to report observations. By defining and effectively communicating the specifics of what should be reported – including clear examples and categories of near misses – we can ensure that staff understand the importance of reporting, the mechanics of reporting accurately and the role they play in prevention.

Furthermore, leadership must alleviate any fear of repercussions that staff may have. 

Leadership is responsible for establishing a transparent and supportive environment where staff feel safe to report near misses without fear of blame. This approach fosters a culture of learning by focusing on systemic improvements rather than solely on human factors.

Q. How can healthcare providers save time reporting on near misses?

A. Technology greatly enhances the near-miss reporting process by providing healthcare workers with easily accessible tools, allowing them to report observations swiftly and maintain their primary focus on patient care. A reporting tool can be seamlessly integrated into daily workflows by adding shortcuts to all terminals and devices, or by placing QR codes in strategic locations throughout the facility for easy access. This intuitive system ensures that it is conveniently available for use.

We've dramatically reduced the time required to complete and submit a report – from typically over 20 minutes using conventional methods, down to less than two minutes. This dramatic decrease reduces paperwork and frees up valuable time for healthcare providers to focus more on patient care.

The risk team receives real-time notifications about the potential risk, allowing them to eliminate a potential root cause before harm occurs. Such systems enhance the care environment with their instant notifications, alerting leadership to issues immediately and allowing for swift responses. 

When one behavioral health client implemented near-miss reporting, the provider experienced a significant improvement, decreasing the time to address and resolve issues by 75% – from 20 days to five days. Such rapid response is critical for ensuring patient safety.

Q. How can providers best use near-miss reports to track trends across different shifts and locations?

A. Near-miss reports track trends and identify safety concerns across different shifts and locations in healthcare settings. Providers are effectively harnessing this data using advanced tools like root cause analysis, data visualization and trend benchmarking. These technologies transform complex datasets into clear, actionable insights, enabling proactive responses to safety concerns.

Many healthcare providers have needed help with analyzing vast amounts of incident data effectively. 

Without the data analytics technology and automation, pinpointing trends in incident reports was time-consuming, often resulting in incomplete analyses. However, with the implementation of sophisticated analytical tools and benchmarking automation, this data can now fully inform performance improvements and facilitate the implementation of real preventative measures.

To illustrate the impact of these tools, consider the experience of one of our client hospitals, which initially struggled to identify the root cause of medication errors. After integrating a patient safety and incident reporting system into their processes, they identified the root cause in the pharmacy. Powered by data aggregation and analytics, this group tackled the issues head-on and achieved a remarkable 51% reduction in medication errors within three months.

Q. How does incident reporting improve employee engagement and organizational culture?

A. A staggering 89% of our clients report improved employee performance satisfaction after implementing reporting systems. Additionally, 74% have observed significant improvements in targeted safety areas within 90 days of using our services. This data underscores the profound impact that efficient incident reporting has on overall workplace satisfaction and safety outcomes.

By fostering employee buy-in around incident reporting, organizations can shift from a reactive to a proactive approach in healthcare safety management. 

This proactive involvement significantly alters the organizational culture as it moves away from merely reacting to incidents. Instead, it encourages preemptive identification and resolution of potential safety issues, embedding a culture where safety is a shared responsibility across all levels of the organization. This shift is essential for maintaining a continuous and robust culture of safety, ensuring that every team member feels empowered to contribute to safer healthcare environments.

Achieving such a transformation requires strong leadership. Nearly all of our clients highlight the critical role of executive buy-in. Leaders must not only support these initiatives but also actively promote and sometimes incentivize incident reporting.

Q. Speaking of leadership, why does it play such a big role in improving patient safety?

A. Leaders must provide safe channels for reporting. 

Implementing confidential and even anonymous reporting systems can drastically change how safety issues are reported. These systems assure staff that they can raise concerns without fear of jeopardizing their jobs or reputations.

Research published in the Journal of Hospital Medicine indicates that having an anonymous reporting system in place can increase the reporting of medical errors by 54% and near misses by up to three times compared to non-anonymous systems. Studies on workplace wrongdoing further support this idea, revealing that 70% of employees are more likely to submit reports when their anonymity is protected.

Patient safety transformation fundamentally starts at the top, with leadership serving as the cornerstone of any successful healthcare safety initiative. 

Effective leaders catalyze change by embodying the principles of transparency and accountability. By openly discussing incidents and the subsequent lessons learned, rather than assigning blame, they not only build trust but also underscore a deep organizational commitment to continuous improvement.

This approach sets a powerful precedent, demonstrating that the focus is on enhancing outcomes and fostering a supportive environment, inspiring confidence and motivating the entire organization to strive for a higher standard of patient care.

Finally, the role of feedback loops cannot be overstated. When management actively responds to reports and communicates the actions taken, it reinforces the value of speaking up. It shows everyone that their voice matters and their contributions lead to safer healthcare environments. 

Moreover, these feedback loops are vital for facilitating incremental change. By systematically addressing and learning from each report, small adjustments accumulate over time, leading to significant improvements in patient safety and organizational culture.

Andrea Fox is senior editor of Healthcare IT News.
Email: afox@himss.org
Healthcare IT News is a HIMSS Media publication.