Overcoming Barriers to Error Reporting: Individual, Organizational and Regulatory Issues

Session
Patient Safety and Quality

Authors
Krisanne Graves
Clinical Quality Improvement Analyst
University of Texas
M. D. Anderson Cander Center

Debora Simmons
Senior Clinical Quality Improvement Analyst
University of Texas
M. D. Anderson Cander Center

Jason M. Etchegaray
Systems Improvement Analyst
University of Texas
M. D. Anderson Cander Center

Description
This multimedia presentation describes medical event reporting and individual, organizational and regulatory barriers associated with implementing successful programs to drive change. Examples and results will be presented from two reporting systems; UTCCRS for close calls and HASP for errors; and a statewide survey of nurses on barriers to reporting.

Abstract
The Institute for Healthcare Excellence at The University of Texas M. D. Anderson Cancer Center has developed proactive projects to drive change and improve patient safety.

The projects include:

1) University of Texas Close Call Reporting System (UTCCRS), www.utccrs.org - a voluntary, anonymous, web-based close-call reporting system active in twelve healthcare institutions. System alerts are distributed when high risk issues or trends are identified.

2) Healthcare Alliance Safety Partnership (HASP), www.texashasp.org - a pilot program evaluating an alternative to nursing peer review, a first in the nation partnership between the Board of Nurse Examiners and three institutions. HASP applies research-based methodologies developed by Reason (1990) and Eindhoven (Aspden, 2003) to examine human performance and systems factors in the analysis of an event. The analysis output is an action plan designed to address individual and/or organizational contributing factors. Successful completion of the action plan results in immunity from licensure action.

3) State-wide survey about barriers to reporting errors - measures attitudes and barriers to reporting events from nurses in the State of Texas and recommends future areas of research.

This multimedia presentation will discuss the common themes across these projects and describe action plans that have successfully reduced errors.