SAFE reporting system at KGH highlighted at national symposium

By Michael Onesi
Kingston General Hospital’s ability to find out why bad things happen to patients has resulted in a good thing for Dr. Roy Ilan and members of the critical care program’s patient safety and quality improvement committee.

An abstract entitled Patient Safety Reporting: A Critical Care Program’s Experience (written by Roy, Critical Care Director Mae Squires, D4ICU Program Manager Christina Panopoulos, and Biostatistician – Research Development Andrew Day) was accepted as a poster presentation at the Canadian Healthcare Safety Symposium which ran Oct. 22-24 in Montreal.

“It’s nice to know your work is valued and appreciated by others in your field,” Roy said, noting the conference is the number one health-care safety event in Canada and one of the major ones in the world.

The abstract focused on the success the critical care program had implementing its SAFE Reporting program, which Roy describes as reporting “when bad things happen to patients.”

The program was designed to get more hospital staff to report accidents so the committee can try to find a solution to ensure the problem never happens again.
This new system dramatically increased reporting – the committee received more than 300 reports over a 12-month span.

Roy said the key was changing the culture around reporting. SAFE Reporting tried to make the process blame free, using techniques such as allowing people to report anonymously.

“When you look at the original unusual occurrence reporting system, reporting rate was quite low. Some people saw it as a way to clear themselves from any guilt or try to find somebody else responsible. This misses the entire role of reporting,” said Roy, who came to KGH two years ago.

“We want to know why things happen. If we made a mistake then what can we do to make sure it doesn’t happen again? We are not trying for a blame-and-shame approach.”

Another change was to allow staff to report when an accident almost occurred.
“Just because nothing bad happened doesn’t mean you can’t learn from it,” Roy said.

This approach has now been adopted in the new hospital-wide SAFE Reporting System which has recently gone through another change – the reporting is now done online.

The SAFE Reporting System was originally started at a hospital in Seattle. It was put together at KGH by staff from ICUs on Kidd 2 and Davies 4.