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Furthering its commitment to patient safety and quality care, BWH has begun implementing a new adverse event reporting system. The Dr. Quality Risk Prevention and Management System offers a web-based format that allows easier reporting and an improved method of tracking and analyzing data. While the system is already in use on 14ABCD and in the Emergency Department (ED) and the Neonatal Intensive Care Unit (NICU), it is anticipated that the entire hospital will be converted from BICS to the web-based reporting system by the end of the year.
“It is our hope that because the web-based system is so easy to use that it will actually encourage people to report,” said Janet Barnes, RN, director, Risk Management. “The goal of this system is not only to increase reporting, but also to get people to think differently about patient safety. We want all staff to see BWH as a leader in patient safety and to know that they will be supported when identifying situations that pose risk.”
While the BICS automated reporting system was ahead of its time in many respects, the web-based format offers several key features that fill in the gaps where the BICS system fell short. For instance, a form can be completed in only three to four minutes – an 80 percent faster turnaround than the previous BICS system. Forms can also be partially completed and returned to later if needed.
In addition to an enhanced, user-friendly reporting module, complete with drop-down menu features, the new system also allows for improved analysis. Managers and members of the Risk Management Department and Patient Safety Team can track trends, develop reports and make recommendations for improvements based on feedback from employees.
“The new web-based system is much easier to use and allows us to describe errors in greater detail with much more flexibility,” said Debby Gayoski, RN who also worked as a trainer for the system in the ED. “Being able to partially complete a form if you are interrupted is a huge improvement,” she added. “In the ED we have seen an increase in near miss reporting. In one case these reports allowed us to isolate a problem and make an immediate improvement.”
In addition to formal training, the educational component of the new system has focused on ways to create a culture that accepts and supports the correct and thorough reporting of adverse events and near misses.
“We want to dispel the myth that there is a punitive system here at BWH,” said Barnes. “We know everyone makes mistakes. The goal of this system, through increased reporting, is to track adverse events and potential mistakes. With more information, we can then improve the system, making it increasingly difficult for adverse events to occur.”
For more information about adverse event reporting and the implementation of the new web-based system, contact Barnes via email (jbarnes1@partners.org) or Erin Graydon-Baker, manager, Patient Safety (egraydonbaker@partners.org).