Instituting patient safety rounds can boost adverse event reporting in outpatient cancer clinics
Research Activities, November 2009
Health care organizations that strive to protect their patients' safety often encourage staff members to report potentially harmful practices, such as providing the wrong dose of a medication or issuing identical hospital identification numbers. From 2003 to 2004, two chemotherapy infusion units at the Dana-Farber Cancer Institute in Boston conducted 45-minute patient safety rounds every other week to elicit reports about conditions that staff believed were unsafe for patients. As a result of the rounds, patient safety event reporting increased substantially, according to a new study by Saul N. Weingart, M.D., Ph.D., of Harvard Medical School, and colleagues. To prepare staff members for biweekly rounds, one unit had a volunteer patient safety champion; the other had a recruited champion. These champions can positively influence incident reporting by encouraging participation in rounds, prompting staff to identify events, and educating staff, the authors suggest. In fact, the unit with the self-identified champion saw an increase from 5.6 incidents reported per day in 2003 to 8.7 incidents per day during 2004.
Likewise, the unit with the recruited champion saw an increase from 5.4 incidents per day to 7.6 incidents per day. However, the researchers could not conclude that recruiting a champion led to the uptick in incident reporting for the unit. Instead, the maturing of the patient safety rounds program and the subsequent enhanced ability of staff members to identify potential harms may have prompted more reports, they assert. The incidents reported most often involved medications (30 percent). For instance, on the unit with the self-identified champion, safety reports involving medications increased from 19 to 30 percent over the course of the study, and the recruited champion's unit saw reports rise from 19 to 43 percent. This study was funded in part by the Agency for Healthcare Research and Quality (HS11644). See “Enhancing safety reporting in adult ambulatory oncology with a clinician champion: A practice innovation,” by Dr. Weingart, Jessica Price, J.D., Deborah Duncombe, M.H.P., and others in the July-September 2009 Journal of Nursing Care Quality 24(3), pp. 203-210.