Identification and Reporting Unsafe Conditions

Patient safety continues to be a point of focus for healthcare leaders in the United States (US). Despite longstanding efforts regarding patient safety in US hospitals, preventable medical errors continue. Within the healthcare industry, reliability is seemingly viewed as a top priority when caring for patients in a hospital setting. The purpose of this quality improvement project was to implement high reliability organization (HRO) principles on a pilot test unit; specifically, skills to help frontline staff identify and report unsafe conditions to improve safety and quality of patient care at the Veterans Affairs Medical Center in Salt Lake City. This project underlines this need to reduce medical errors through early detection and reporting of unsafe conditions. Identification and reporting of said conditions offer a superior, proactive approach to improving safety within hospital settings as opposed to the current root-cause analysis method. Results from an Oro 2.0 organizational assessment used to assess HRO maturity identified the focus for this project. The intervention included an educational session developed using current evidence from the literature and iterative feedback from stakeholders that focused on identification and reporting of unsafe conditions and near miss safety events. Concurrently, a culture change campaign was initiated at the organizational level. The intervention was piloted on a single nursing unit. A pre- and post-test consisting of four-point Likert scale questions was used to evaluate learning. Near miss event reporting was tracked before and after the intervention. The results from this project found no statistical significance from the pre- and post-test survey data. However, a substantial increase in reporting resulted during the five-month period following the intervention. This project demonstrated that improved knowledge of unsafe conditions in the healthcare environment can lead to improved reporting and thus proactive measures to prevent patient harm. More time is needed to fully understand the potential long-term benefits of this work, including reduction of serious safety events and advancement in HRO maturity at the organizational level.