Crandall Kristen M, Almuhanna Ahmed, Cady Rebecca, Fahey Lisbeth, Floyd Tara Taylor, Freiburg Debbie, Hilliard Mary Anne, Kalburgi Sonal, Khan Nafis I, Patrick DiAnthia, Pavuluri Padmaja, Potter Kelvin, Scafidi Lisa, Sigman Laura, Shah Rahul K
Children's National Health System, Washington, D.C.
The George Washington University School of Medicine and Health Sciences, Washington, D.C.
Pediatr Qual Saf. 2018 Apr 6;3(2):e072. doi: 10.1097/pq9.0000000000000072. eCollection 2018 Mar-Apr.
In 2014, Children's National Health System's executive leadership team challenged the organization to double the number of voluntary safety event reports submitted over a 3-year period; the intent was to increase reliability and promote our safety culture by hardwiring employee event reporting.
Following a Donabedian quality improvement framework of structure, process, and outcomes, a multidisciplinary team was formed and areas for improvement were identified. The multidisciplinary team focused on 3 major areas: the perceived ease of reporting (ie, how difficult is it to report an event?); the perceived safety of reporting (ie, will I get in trouble for reporting?); and the perceived impact of reporting (ie, does my report make a difference?) technology, making it safe to report, and how reporting makes a difference. The team developed a key driver diagram and implemented interventions designed to impact the key drivers and to increase reporting.
Children's National increased the number of safety event reports from 4,668 in fiscal year 2014 to 10,971 safety event reports in fiscal year 2017. Median event report submission time was decreased by nearly 30%, anonymous reporting decreased by 69%, the number of submitting departments increased by 94%, and the number of reports submitted as "other" decreased from a baseline of 6% to 2%.
Children's National Health System's focus on increasing safety event reporting resulted in increased organizational engagement and attention. This initiative served as a tangible step to improve organizational reliability and the culture of safety and is readily generalizable to other hospitals.
2014年，儿童国家医疗系统的执行领导团队向该机构提出挑战，要求在3年内将自愿提交的安全事件报告数量增加一倍；目的是通过强化员工事件报告来提高可靠性并促进我们的安全文化。
遵循唐纳贝迪安质量改进框架的结构、过程和结果，组建了一个多学科团队并确定了改进领域。该多学科团队专注于3个主要方面：报告的感知难易程度（即报告一个事件有多难？）；报告的感知安全性（即我报告会惹麻烦吗？）；以及报告的感知影响（即我的报告有作用吗？）技术，使报告变得安全，以及报告如何产生影响。该团队绘制了关键驱动因素图并实施了旨在影响关键驱动因素并增加报告数量的干预措施。
儿童国家医疗系统将安全事件报告数量从2014财年的4668份增加到2017财年的10971份。事件报告提交时间中位数减少了近30%，匿名报告减少了69%，提交部门数量增加了94%，作为“其他”提交的报告数量从基线的6%降至2%。
儿童国家医疗系统对增加安全事件报告的关注导致了组织参与度和关注度的提高。这一举措是提高组织可靠性和安全文化的切实步骤，并且很容易推广到其他医院。
