Improvements in Reporting Adverse Events
December’s Patient Safety Update described the adverse event reporting process. The Risk Management Department is responsible for investigating adverse patient events that are reported either through the BICS automated incident reporting system or that are reported directly to the Department. The Department is also responsible for event reporting to the Board of Registration in Medicine, the Department of Public Health and the Food and Drug Administration. Prompt reporting of adverse events to the Department allows for timely investigation, including root cause analysis if the reported event is determined to be a sentinel event, identification and assessment of risk issues, as well as advice and support to staff. The Department collaborates with Quality Management and the Patient Safety Team in developing corrective measures in response to particular adverse events.
BWH has also instituted a new adverse event reporting policy that supports staff who bring events to light for improvement opportunities (The new policy can be found on-line in by accessing Guidelines/Handbook/Medical-Legal Policies/ 5-18 Adverse Event Reporting Policy in the BICS system).
Beginning in April, BWH is piloting an exciting new web-based reporting system that will replace the BICS reporting system. The pilot areas are 14ABCD, the Emergency Department and the Newborn Intensive Care Unit. The new reporting system offers us several improvements over the BICs system. The web-based reporting system takes only a few minutes for the reporter to accurately complete a report. Also, the reporter can save a partially completed report if he/she is interrupted. In addition, the system encourages and supports near miss reporting. Near miss events are a rich source of information for systems improvements. In the near future, the Risk Manager, Nurse Manager or Patient Safety Manager will be able to provide feedback to the reporter when processes have been improved as a result of their report. The new system will eventually provide an all-inclusive platform to report, trend, and track events, and staff will have the ability to see trends occurring in their areas to further facilitate improvement efforts. We'd like to take this opportunity to thank the pilot units for their support and expertise in helping us to develop this product.
For any questions or concerns, email Tejal Gandhi, MD; Janet Barnes, RN, JD or Erin Graydon-Baker, RRT.