The University of New Mexico Hospital’s Process Improvement Team is responsible for leading data-driven process improvement efforts throughout the institution. It is leading a cultural shift toward a safety culture. This requires all team members to start looking at patient safety proactively, rather than reactively. Reporting “good catches”—events that don’t reach the patient—is an indicator of this shift.
UNM Hospital aimed to create a reporting mechanism, system, and training to help move the hospital toward a safety culture in which both self-reporting and near-miss patient safety event reporting are encouraged and celebrated to correct systemic weakness and create a safer environment for patients and employees.
This led to the development of the Patient Safety Portal event reporting system and training.
Program Details
With a heavy focus on near misses and good catch reporting, the training program featured 45 courses for a total of 225 learners. Individuals who reported events that had the potential to cause harm but did not because of timely intervention were spotlighted in the “We Care Recognition of the Day” section of the hospital’s organization-wide communication published biweekly.
Data reviewed identifies both system-wide failures, as well as opportunities for improvement at the unit and area level. This system led to the creation of 89 unit-level and area-level Patient Safety Review Committees with the purpose of analyzing patient harm events and good catches to improve processes. Prior to this initiative, there were only a handful of functioning review committees throughout the institution, highlighting a 94 percent increase in the creation and use of these vital committees. Sharing data and wins with the hospital through the weekly organization-wide leader meeting, Management Coffee, leverages this momentum by using the information to inform process improvement in each unit/area to improve patient safety and mitigate risks highlighted in the patient safety system.
Results
Data shows an increase in good catch and near-miss reporting concurrent to a decrease of reported harm events. As a result of the training, the number of medication-related patient safety harm events decreased 34 percent from fourth quarter 2021 to first quarter 2022. Concurrently, there has been a 271 percent increase in good catch reporting.
By moving toward an institution-wide safety culture and preventing patient harm events, UNM Hospital is decreasing the likelihood of readmissions.