Program Information
Durable Improvement in Patient Safety Culture at 5 Years with Use of High-Volume Incident Learning System
P Hartvigson1*, G Kane1 , L Jordan1 , A Kusano2 , E Ford1 , (1) University of Washington, Seattle, WA, (2) Anchorage Radiation Therapy Center, Anchorage, AK
Presentations
TU-FG-702-5 (Tuesday, August 1, 2017) 1:45 PM - 3:45 PM Room: 702
Purpose: In 2012 our department started a comprehensive incident learning system (ILS) which focuses on high-volume incident reporting, primarily of near-miss events. Prior research of our institutional experience at two years found an improvement in multiple parameters of patient safety culture. Here we assess our safety culture at five years to ascertain its durability of improvements attributable to ILS.
Methods: Prior to initiating the departmental ILS in 2012 a survey assessing patient safety culture was sent to all staff to establish a baseline. The survey draws from a validated AHRQ-tool and consists of 50 questions using five-point Likert scales. The same survey was collected annually for the subsequent five years. Three key aspects of safety culture directly related to the safety initiative were analyzed. Mean response scores were compared to baseline using t-test for statistical significance. Changes in overall safety grade and perceived barriers to reporting safety incidents were examined.
Results: A high volume of reports continued during the five years of this study (4698 reported events; average of one safety-related report per patient). The survey response rate was >78% each year. Sustained improvements were observed in the following areas: open communication and punitive concerns (p < 0.01), responsibility and self-efficacy (p < 0.01), and feedback (p < 0.01). The percent of respondents returning the highest safety grade of “excellent” doubled and has remained above baseline. Perceived barriers to reporting safety events decreased and remained below 2012 levels with the exception of reluctance to admitting liability.
Conclusion: Comprehensive incident learning resulted in significant improvements in patient safety culture which persisted over a five year period. Our findings suggest the benefits of adopting high-volume incident learning are durable, and offer further evidence in favor of the broader adoption of such initiatives by other institutions.
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