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Signs of Improvement

“Are we doing better?” is a loaded question. Measuring what matters for patient safety is particularly challenging. However, there are some useful progress indicators, and one in particular is showing significant improvement in those hospitals reporting events to CHPSO.

Improving knowledge of organizational risks through encouraging event and unsafe condition reporting is a necessary component of high reliability. Optimizing that requires many actions, including instituting a culture that acknowledges that many events are not someone’s “fault”, increasing internal communication, feedback relating to reports so that employees see the value of reporting, and helping staff recognize potentially unsafe conditions.

A simple measure of improvement is examining the severity of events reported. In an institution with a poor reporting culture, reporting is seen as a defensive action. Many events reported will be high-severity, as those are the events most likely to be “found out” by someone else. Near misses, unsafe conditions and no-harm events are much less likely to be reported.

As the reporting environment improves, more near misses, unsafe conditions and no harm events will be reported. This may inflate the number of safety reports even in the face of an improving safety climate and improving outcomes. However, measuring the percentage of events that are high severity is a simple method of assessing improvement even when the total number of events is changing from month to month, as a decline in high severity events will occur with either improved reporting or improved safety, both of which are desirable.

The majority of events CHPSO currently receive are scored by hospitals according to the NCC-MERP harm scale and only those reports were used for the following graph. The following chart shows the change over time of the high-harm events as a percentage of total reports. The vertical axis shows percentage of total reports that are assigned a score of G, H or I (permanent harm, life threatening or death), and the horizontal axis shows the month and year, formatted as yyyymm. Over 400,000 events are represented, and there is a strong temporal decreasing trend.

Reference

Lekka C. High Reliability Organisations: A Review of the Literature. London; 2011. http://www.hse.gov.uk/research/rrpdf/rr899.pdf