“If you have leaders pushing away reports, being smug, and not creating the right culture, problems follow,” said Dr. Shah. “With any size of practice, you need to talk about safety and quality. It doesn’t have to be formal, and don’t overthink it. Something as easy as a safety huddle a couple of times a week goes a long way toward shaping the culture.”
Explore This IssueDecember 2017
Key components of a successful event reporting system include:
- A supportive environment that protects the privacy of the staff reporting occurrences;
- Reporting mechanisms that are easily accessed by the entire team, not just physicians and nurses;
- Summaries of reports and actions taken that are disseminated in a timely fashion so the staff knows their reports are important and are taken seriously; and
- Mechanisms in place to ensure that the responsibility for reviewing reports and developing action plans is clearly outlined.
“Medicine is very much a team sport, and there is a growing awareness that inter- and multidisciplinary teams are critical in achieving favorable outcomes for the patient,” said Dr. Brenner. “Start with the first person who touches the patient, either literally or virtually, including the front desk, nursing and medical assistants, and any other ancillary service. We are absolutely all in this together.”
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Physicians and their staffs shouldn’t be intimidated by an imposing and confusing set of concerns. “Practices don’t realize that they can lean on the performance and quality improvement departments of the hospitals they have affiliations with,” said Dr. Shah. “These departments can help with materials, literature searches, and plan-do-study-act cycles. They can leverage both these resources and those available from [their] malpractice insurance provider.”
Finding and addressing WPEs are part of the do-no-harm promise physicians make to their patients every day. “If you are not a constant student of safety and quality and you are not a student of your results as a physician, then you are not going to get better,” said Dr. Brenner. “If there was nothing to be done, we’d counsel patients that these things happen, but it wouldn’t change lives much. The fact that we know that by doing some simple things we prevent these ‘wrong’ things puts the onus squarely on us to find and act on them.”
Kurt Ullman is a freelance medical writer based in Indiana.