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Archived Service Delivery Profile:

Voluntary System to Report and Analyze Nursing Errors Leads to Patient Safety Improvements


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Snapshot

Summary

The Healthcare Alliance Safety Partnership was a 3-year quality improvement pilot project involving a board of nursing and three hospital systems in developing a voluntary, nonpunitive system for reporting, investigating, and analyzing nursing errors. During the 3 years of reporting, nurses reported incidents to the partnership. Then, nurse analysts performed an extensive investigation and worked with a multidisciplinary committee to make prescriptive recommendations to the nurse and institution regarding organizational, individual, and technical improvements that could be made to reduce the chance of recurrence. Although numbers of participating nurses were limited, the changes made by the hospital systems helped to address a wide variety of safety problems that were directly under the control of these organizations and led to the adoption of a multitude of quality improvements.

Evidence Rating (What is this?)

Suggestive: The evidence consists of anecdotal, post-implementation data on how participating institutions responded to the Healthcare Alliance Safety Partnership recommendations.
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Developing Organizations

St. Luke's Episcopal Hospital, Houston, TX; Texas A&M Health Science Center; Texas Board of Nursing; Texas Children's Hospital; Texas Hospital Association; University of Texas M.D. Anderson Cancer Center, Houston, Texas
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Date First Implemented

2005
The pilot was implemented from July 2005 to June 2008.

Problem Addressed

Many actual and potential medical errors occur in hospitals on a daily basis, and these events represent significant opportunities to catch, learn from, and correct mistakes before they harm patients. But many such occurrences go unreported, thus negating the opportunity for learning and improvement.
  • Many errors, leading to injury and death: The Institute of Medicine's seminal 1999 report, To Err is Human: Building a Safer Health System, estimated that between 44,000 and 98,000 deaths each year occur in hospitals because of medical errors.1 According to the sixth annual Patient Safety in American Hospitals study, patient safety errors resulted in 913,215 patient safety events that occurred in the care of U.S. Medicare patients, costing the Medicare program $6.9 billion between 2005 and 2007.2 Medication errors alone injure at least 1.5 million Americans annually, costing the nation more than $3.5 billion a year.3
  • Many unreported errors: Errors in most health care settings frequently go unreported. Several factors contribute to low reporting rates, including: a belief that errors need not be reported unless they cause life-threatening harm; fear of reprimand; disagreement over whether an error occurred; anticipated negative responses to errors by hospital leadership; and the significant time and effort required to report an error.4
  • Reporting errors as an opportunity for improvement: The reporting of errors provides an opportunity for indepth analysis, which, in turn, can lead to the development and implementation of changes (e.g., simulation training, checklists) designed to prevent a future recurrence. The Institute of Medicine recommends a nonpunitive approach to error reporting, believing that it will lead to system improvements and a culture that is more focused on patient safety.1,5

What They Did

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Description of the Innovative Activity

The Healthcare Alliance Safety Partnership was a 3-year quality improvement pilot project involving a voluntary, nonpunitive system for reporting, investigating, and analyzing nursing errors. During the 3 years of reporting, nurses reported incidents to the partnership. Then, nurse analysts performed an extensive investigation and worked with a multidisciplinary committee to make prescriptive recommendations to the nurse and the institution regarding organizational, individual, and technical improvements that could be made to reduce the chance of recurrence. The pilot ran from July 2005 to June 2008; results and implications are currently being evaluated. Key elements included the following:
  • Report submission to the Healthcare Alliance Safety Partnership: Eligible participants included nurses at three participating hospitals. Nurses who submitted an event report were also required to file an incident report within their own organization.
  • Research and discovery: The discovery phase included a review of the event to make sure that it meets the criteria for inclusion, followed by an indepth investigation by a nurse analyst. Key elements of this phase are described below:
    • Screening against program criteria: A nurse analyst reviewed the event report to ensure that it did not meet one of the program's exclusion criteria, which included events that contributed to a patient death or serious injury; were intentional; or involved a knowing violation of safe operating principles, criminal activity, substance abuse, or intentional falsification.
    • Texas Board of Nursing contact: The analyst notified the Texas Board of Nursing about the report and asked the board to verify the nurse’s license and check for past reportable conduct.
    • Indepth research on the event: The analyst conducted extensive research into the event, including interviewing the nurse and other involved parties; reviewing the institution’s relevant records (including any incident and root-cause reports on the event), policies, and procedures; and visiting the hospital to observe clinical practice and to assess the institutional and technological environment. The nurse analyst compiled all gathered evidence into a case book.
  • Analysis and recommendations: The analyst conducted a comprehensive assessment to determine all the contributing factors and processes that led to the error, and met with a multidisciplinary committee to develop a corrective action plan.
    • Cause identification: The analyst identified and grouped contributing factors by creating a cause map, which visually depicts systems factors (i.e., technical, organizational, and patient related) and human performance factors (i.e., knowledge based, rule based, and skill based) related to the event, and illustrates how these factors interacted and contributed to the error.
    • Literature review: The analyst searched the literature and national databases for similar errors to identify patterns and circumstances that could inform the current analysis.
    • Event Review Committee and action plan: The analyst presented the case book and cause map to an Event Review Committee, which consisted of six individuals: a chief nursing officer from one of the participating hospitals, a Texas Board of Nursing member, a chair of a peer review committee, the nurse analyst, a facilitator, and an administrative assistant. During the meeting, the committee reviewed all materials and created a corrective action plan with recommendations for the nurse and the participating institution, including interventions designed to address organizational, individual, and technical factors, with recommended timelines for completion of action items.
  • Resolution phase: The institution and the nurse involved notified the event review committee regarding actions taken in response to the corrective plan. This process continued until the committee approved these actions, indicating satisfaction that resolution of the issue was complete. The Healthcare Alliance Safety Partnership then provided a final report to the Texas Board of Nursing.

Context of the Innovation

The University of Texas MD Anderson Cancer Center, St. Luke’s Episcopal Hospital, and Texas Children’s Hospital are all part of the Texas Medical Center, which includes 11 not-for-profit medical institutions that collectively handle approximately 5.5 million patient visits annually and employ more than 26,000 registered nurses, licensed vocational nurses, clinical caregivers, technicians, and medical support staff. The Texas Board of Nursing regulates the licensure, education, and practice of more than 278,000 nurses in the state. The Healthcare Alliance Safety Partnership was developed after the passage of Texas Senate Bill 718, which called for development of alternative reporting systems for nursing errors. In response to this bill, the Texas Board of Nursing issued a proposal calling for the development of pilot programs to test innovative methodologies, prompting the University of Texas MD Anderson Cancer Center to propose development of the partnership program. The proposal process was led by Eric J. Thomas, MD, MPH, associate professor of medicine at the University of Texas Houston Medical School, a nationally known expert on translating best practices from other industries (particularly aviation) to health care.

Did It Work?

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Results

Although no hard data are available, the pilot project led to the adoption of a multitude of concrete patient safety improvements that were made in response to a review of 18 cases at the three institutions. These changes helped to address a wide variety of safety problems that were directly under the control of these organizations. An example of how the review of one case led to improvements is provided below:
  • Incident: In September 2005, a nurse caring for a premature baby at Texas Children’s Hospital accidentally infused breast milk into an intravenous (IV) tube rather than a nasogastric enteral feeding tube. The nurse discovered her error immediately and self-reported it internally and to the partnership. (The baby suffered no adverse outcomes.)
  • Causal factors: Three main factors were found to have contributed to the error. First, the universal connectivity of adapters allows IV lines to be connected to enteral and other lines; there are no forced constraints in the design of the equipment. Second, “cognitive slips” (lapses in focus perception or memory) are common when providers perform routine activities. Third, specialized enteral feeding pumps typically run a larger volume of fluids per hour than are appropriate for a low-birth-weight baby; as a result, a medication pump, which can be set at a low infusion rate, is often used for enteral feeding in neonatal populations.
  • Resulting patient safety improvements: Although the Healthcare Alliance Safety Partnership conducted its review, Texas Children’s Hospital took immediate steps to reduce the risk of a similar error, including marking all orogastric and nasogastric tubes and feeding pumps with orange labels and researching alternative equipment options. The Healthcare Alliance Safety Partnership ultimately made the following recommendations, all of which were implemented by the hospital:
    • Adopt clear labeling at the proximal and distal end of each tubing connection.
    • Develop a policy that reinforces tubing connection labeling and training.
    • Aggressively work with manufacturers to design an enteral feeding pump with slow infusion rates appropriate for premature babies.
    • Along with other institutions, lobby manufacturers to reevaluate the use of universal adapters.
  • Net impact: Since the original incident, no other similar errors have been reported at Texas Children’s Hospital. In addition, the Healthcare Alliance Safety Partnership prompted The Joint Commission to issue a Sentinel Alert on tubing misconnections, which should lead to a reduction in similar events in other organizations.

Evidence Rating (What is this?)

Suggestive: The evidence consists of anecdotal, post-implementation data on how participating institutions responded to the Healthcare Alliance Safety Partnership recommendations.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Laying the groundwork: Dr. Thomas and Sharon Martin, formerly the vice president for process improvement at the MD Anderson Cancer Center, gathered a group of stakeholders from participating organizations to build consensus about the project’s goals. These organizations signed agreements to ensure confidentiality.
  • Institutional Review Board approval: Each health care institution cleared its participation in the partnership with its respective institutional review board.
  • Developing the reporting system: The group reviewed the Aviation Safety Action Program—which encourages airline pilots to self-report errors and near-errors—and translated the process steps for this program to the health care setting.
  • Creating the Event Review Committee: Each participating institution selected individuals to participate on the committee.
  • Hiring nurse analysts: Two nurse analysts were hired to review cases submitted to the partnership.
  • Soliciting participation from nurses: Each nurse who worked for a participating institution received a brochure about the Healthcare Alliance Safety Partnership and was invited to attend inservice and other educational sessions on the program. Both the brochures and the educational events highlighted the purpose of the program and specified criteria for events that should be reported.

Resources Used and Skills Needed

  • Staffing: The Healthcare Alliance Safety Partnership program had two dedicated nurse analysts on staff, one of whom served as project director; the discovery and analysis phase for each case required approximately 80 hours of a nurse analyst's time. Event Review Committee members participated on a voluntary basis, with each case review taking approximately 10 hours (including the time needed to design the resolution plan). Several experts from participating institutions and national organizations also voluntarily shared their time and expertise.
  • Costs: The majority of program costs was related to personnel; other costs included telephone and computer access.
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Funding Sources

Agency for Healthcare Research and Quality; University of Texas M.D. Anderson Cancer Center, Houston, Texas; Seton Healthcare Network; American Healthcare Education Centers
The Agency for Healthcare Research and Quality provided a grant of approximately $5 million to fund a number of projects, including the Healthcare Alliance Safety Partnership (AHRQ Grant #1PO1HS1154401). Seton Healthcare Network and the American Healthcare Education Centers also provided smaller grants to support the project. MD Anderson assumed the costs of ongoing operations.end fs

Adoption Considerations

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Getting Started with This Innovation

View the project as a partnership: Member organizations should join the effort as a way to improve safety by learning from errors, and no one organization should be seen as the leader of, or take credit for, the effort.

Sustaining This Innovation

  • Respect and honor differences among participants: Although all partnership participants should focus on patient safety, their stated missions and constituencies may vary significantly. For example, the Texas Board of Nursing focuses on ensuring that each person holding a license as a nurse in the state of Texas is competent to practice safely. In contrast, the Texas Hospital Association represents the interests of member hospitals and health systems on legislative and regulatory issues, supporting their efforts to provide high-quality, cost-effective care. Varying points of view mean that organizational representatives may approach safety-related issues and solutions differently, and these differences should be respected and honored.
  • Encourage transparency: Although unpleasant or uncomfortable information may be uncovered at times, it is critical to remain focused on the ultimate goal of improving patient safety.

More Information

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References/Related Articles

Thomas MB, Simmons D, Graves K, et al. Practice/regulation partnerships: the pathway to increased safety in nursing practice, health care systems, and patient care. Nurse Leader. 2007;5(3):50-4.

Zolnierek C. Hospital Alliance Safety Partnership (HASP): an innovative approach to safety and regulation. Tex Nurs Voice. 2008;2(3):1, 6.

Footnotes

1 Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000.
2 HealthGrades. The Sixth Annual HealthGrades Patient Safety in American Hospitals Study. April 2009. Available at: https://www.cpmhealthgrades.com/CPM/assets/File/PatientSafetyInAmericanHospitalsStudy2009.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.). Accessed January 21, 2010.
3 Institute of Medicine. Preventing medication errors. Washington, DC: National Academies Press, 2006.
4 Mick JM, Wood GL, Massey RL. The good catch pilot program: increasing potential error reporting. J Nurs Adm. 2007;37(11):499-503. [PubMed]
5 Kao LS, Thomas EJ. Navigating towards improved surgical safety using aviation-based strategies. J Surg Res. 2008;145(2):327-35. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 02, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 03, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 10, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.