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Website spotlight: Above and beyond traditional error reporting

Staff Development Weekly: Insight on Evidence-Based Practice in Education, January 20, 2012

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As the fourth leading cause of death in the United States, medical errors just don't seem to be going away. Many healthcare professionals agree that reporting such errors is the only way to learn from them and prevent them in the future. But although most medical centers have systems in place for staff to report errors, oftentimes these systems can be difficult, cumbersome, and seemingly void of any real, noticeable results. Inertia and a sense of "why bother?" sets in, further concealing the flawed systems and their lack of a streamlined way to ensure that the causes of identified ­errors are fixed or improved.

Finding a way to revamp the system of medical reporting might seem just as cumbersome (if not more so) than dealing with what is already in place, but a team of patient safety advocates at the VA Pittsburgh Healthcare System (VAPHS), a three-division, integrated healthcare system that serves the veteran population ­throughout the tristate area of Pennsylvania, Ohio, and West Virginia, decided to establish an alternative method of reporting errors called the Patient Safety Triage Committee (PSTC). Using available technology and anonymous reporting, the PSTC was able to create open dialogue with frontline staff in an effort to increase reporting of safety issues, create opportunities for improvement, and solicit innovative ideas to enhance patient safety throughout the medical center.

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Editor’s note: To read more articles like this, visit the Reading Room, part of www.StrategiesForNurseManagers.com.

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