Safety Reporting Fosters Improvements- Clinical & Research News - For and about the Physicians and Researchers of Brigham and Women's HospitalSafety Reporting Fosters Improvements- Clinical & Research News - For and about the Physicians and Researchers of Brigham and Women's Hospital

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Safety Reporting Fosters Improvements

BWH’s Web-based Safety Reporting System is one important way for all staff to provide feedback about potential safety issues. The reports are read by a unit manager, risk managers and process owners who are experts in different types of reports, such as medications, lab or radiology.

Staff should file a safety report if a patient is harmed, if the event reaches a patient but causes no harm or when they have a patient safety concern, even if a patient is not involved.

In February, staff filed 539 safety reports through the system. The Safety Reporting feature is included in Partners Applications on computer Start menus. The following projects and improvements are a result of those reports.

  • Pharmacy system and eMAR dictionaries were updated to allow for fractional dose prompt for Sinemet
  • Prisma System Operator’s Manuals were updated with additional warnings; all Prisma machines are labeled with additional warnings on alarm management; and training materials regarding alarm management have been distributed
  • Power covers were installed on all electric beds in the OR and the joints were sealed with silicone to minimize the possibility of fluids coming in contact with outlet connectors
  • Shiftly checks on 10CD were instituted to ensure bed alarms are functioning
  • Interventional Radiology is updating Standard Registry forms to include a checkbox pertaining to catheter dressing and end caps
  • Plans are in the works to change the Soundex system to prevent mistaken ordering of sound-alike medications
  • Plans are underway to investigate improved picking of epidurals in Pharmacy System after/with implementation of new epidural templates
  • Plans are underway to investigate improved picking of epidurals in Pharmacy System after/with implementation of new epidural templates
  • Changes are planned in Pharmacy System to make the time the last dose was given more apparent to pharmacists approving change orders
  • Small-scale education of nurses, house staff, pharmacists, CPD staff, registration staff, patient care assistants and phlebotomists to help staff think about systems issues and discuss ways of preventing errors.