We Have Come a Long Way, but Every Defect Is Still a Treasure

Way back in January of 2012, I wrote a blog titled, “Every Defect a Treasure.” I did not coin this phrase, but it is extremely helpful to reflect on if you want to make things better. Rather than hiding stories about errors or near misses, true learning organizations see the events as grand opportunities to find weaknesses in their systems that can be fixed to prevent future failures. 

Commercial aviation is a high-risk industry that healthcare is often compared to. Flying on a commercial flight is so much safer than it was in the 1960s and 1970s in large part because the leaders of that industry understood the importance of learning from crashes and near misses. They set up reporting systems, held the reporters harmless, then made changes to aircraft and to the standard procedures of aircraft crews and air traffic controllers based on what they learned.

Starting in the 1990s, healthcare started adopting similar reporting systems to learn from the events and near misses of harm to patients and began changing care based on what they learned. GBMC has been using error reporting systems for quite some time, and our care has gotten so much safer in part because of this work. We have changed our reporting systems as the technology has improved.

So, we recently upgraded our incident reporting system (formerly Quantros/RL Datix) to what we are now calling the STAR Incident Reporting Tool.  This updated system allows us to have convenient access through a mobile device, the Infoweb, or a link on Epic. There are icons for specific safety events, (now including workplace violence) and an icon to enter “Great Saves” (near misses).

This week, I spoke with Carolyn Candiello, our Vice President for Quality and Patient Safety, to find out more about our new tool and what it means for our healthcare system.

Q:  How does this STAR incident reporting tool benefit staff, managers, and the organization?
A:  Ease of reporting— the new software has allowed us to remove certain “mandatory” fields. The “tile” format allows the end user to quickly identify the type of event for reporting, whether a fall, medication error or a Great Save. One of the biggest advantages is the ability to report from your mobile device. I encourage you to visit the GBMC Infoweb for detailed instructions on how to add this to your phone or tablet.  Access to reporting is available through the Infoweb, through the link on every GBMC device and directly through resources in Epic. There is no need to enter patient information as it will populate when accessed via Epic.

Q:  It has been over a week since it went live, how is it going so far?  What has been some of the feedback from your colleagues? 
A:  Feedback has been very positive – we have had over 200 incidents reported today, which reflects a positive safety culture.

Q:  Do you feel that this new tool will encourage more staff members to report adverse events?
A:  We believe making reporting easy helps make our system of care safer. We expect all leaders to encourage reporting when anything happens that wasn’t supposed to happen and to share learning from reported incidents. 

Q:  What role do you envision the STAR tool will have for our health system's ongoing journey as a High Reliability Organization (HRO)?
A:  Sensitivity to operations and preoccupation with failure are two important attributes of an HRO. GBMC promotes these through our Safe Behaviors. You may recognize two of these as “having a questioning attitude” and “paying attention to details.” These attributes of an HRO and our Safe Behaviors have made patient care much more reliable over the years, resulting in hundreds of Great Saves. We hope with the new tool that our culture of reporting will get even stronger.  

I want to thank Carolyn and her staff for all that they do every day to make care safer – to provide the care we would want for ourselves and for our loved ones!

When Something Truly Inhuman Happens

Last week video footage of the tragic death of Tyre Nichols was released. I was outraged and deeply pained to see the horrific video of the beating that resulted in Tyre Nichols’ death.  Tragedies such as this one in Memphis, Tennessee occur too often and is another painful reminder that GBMC’s pursuit of health, healing and hope for our communities is as important as ever and there remains much work to be done.

It is important at times like this that we unite against actions of this sort. Let us rely on our shared commitment to a safe, caring and just community at GBMC Healthcare and beyond. As we navigate these emotionally challenging times, please remember that all GBMC HealthCare system employees have access to the Carebridge Employee Assistance Program, which offers 24/7 support, guidance and mental health counseling if you are struggling to process this event and others like it.

My heart goes out to the Nichols family in their time of tremendous grief.