Take time to develop a plan now, so your organization knows how to respond when a patient is harmed by care.
Take time and be ready before something goes wrong
Know in advance how your organization will respond when a patient is harmed by care. Decide now what first steps you’ll take, how you will communicate with colleagues and patients about the event, and how to get to the bottom of what happened.
Know in advance how your organization will respond when a patient experiences a medical error or adverse event. Decide what first steps you will take, how you will communicate with colleagues and patients about the event, and how to get to the bottom of what happened.
Consider adjusting your current reporting process or design one:
How does a patient or staff member report a problem?
Who collects the information? How is it collected and recorded?
What information is collected/recorded?
Who needs to be involved in an immediate conversation?
Who is responsible for making immediate changes (e.g. removing faulty equipment, stopping administration of incorrectly-labeled medications)? Keep track of staff members and others involved in the event who can later provide more in-depth information for analysis.
Who will gather a team to analyze the event? Conducting a root cause analysis of an adverse event or near miss is a critical step in preventing it from happening again.
How will you report the event externally, if applicable? Many serious events involving patient harm must be disclosed to state and/or federal health authorities.
Who will communicate with patients and/or their families as well as to colleagues when a serious adverse event has occurred? Who will support staff members following the event?
Begin safety efforts proactively
Communicate with every staff member about expectations for how to report concerns and what should be reported, including close calls, adverse events, and problem areas.
Similarly, communicate about expectations for how staff will respond when something goes wrong. Do not wait until something goes wrong to prepare.
Consider including patient representatives on planning activities or safety initiatives.
Use existing huddles or organize specific ones on safety to gather staff feedback and concerns.
Create a process for continued improvement
Patient safety is a continuous process. Soliciting feedback from staff, clinicians and patients will help your organization improve. A successful plan will include ways for patients and families to make their voice heard.
Patients and families can provide valuable insight into a harm event and often appreciate the opportunity to give feedback.
Discuss how your office will provide a forum for patients and families to express concerns and how you will let them know that you are open to their comments.
Be sure this process includes:
a way for patients to speak to a safety contact person,
a way to document the concern, and
a way to make sure there is follow up.
Consider more regular mechanisms for patient input, such as suggestion boxes, surveys, or a dedicated patient liaison.
This page was adapted from the Betsy Lehman Center's Patient Safety Navigator. Visit the Navigator website to learn more about analyzing adverse events, communicating in the aftermath of serious harm, and reporting medical errors to state and federal agencies.
