Published in the June 2006 issue of Today’s Hospitalist
In the quality improvement community, the conventional wisdom says that to prevent errors, hospitals need to collect and analyze data on adverse events to learn from their mistakes. But because many hospitals make reporting errors such a painful process, they may not be getting a complete picture of the problems that take place within their walls.
Suppose, however, that you asked physicians and nurses to provide a brief report at the end of every shift using a form that made reporting quick and easy. Would streamlining the process increase the volume “and quality “of information hospitals receive about adverse events?
That was the question posed by Victoria A. Kellogg, PhD, CRNP, MBA, who knew there had to be a better way to collect information about adverse events. “I worked in hospitals where you have to fill out long forms to report an adverse event,” Dr. Kellogg says. “No one wanted to fill them out because no one wanted to deal with the aftermath.”
That experience gave Dr. Kellogg the inspiration to create a tool she calls the “shift coupon.” The concept is fairly simple: At the end of their shift, health care providers like nurses complete a simple form that asks 12 questions about their shift.
Among other things, the form asks them to identify the unit where they worked, the number and acuity of patients, whether an adverse event occurred, and the nature of that problem. Perhaps most importantly, the form allows nurses to remain anonymous.
To determine if the shift coupon would actually lead to more reporting of adverse events, Dr. Kellogg decided to study the issue. She asked nurses in her home state of Pennsylvania to fill out shift coupons within an hour of completing a shift. A total of 247 nurses working in Pennsylvania hospitals returned at least one shift coupon.
The study, which was published in the January-March 2006 issue of the Journal of Nursing Care Quality, confirmed Dr. Kellogg’s hunch. Many of the adverse events reported on the shift coupon were never reported to hospitals through their formal reporting processes.
An analysis of the study’s results, in fact, found that shift coupons collected significantly more reports on all adverse events (the total number of all types of adverse events), patient complaints, medication errors, family complaints and unplanned admissions to the ICU.
The study found that the type of adverse event most commonly reported via shift coupons was patient complaints, which accounted for 21 percent of reported problems. Examples included incidents where a patient’s sedation wore off because of a delay in a drug’s administration, or a blood pressure cuff that was too tight and caused pain.
Medication errors accounted for nearly 19 percent of the adverse events reported via shift coupons, while family complaints accounted for 17 percent of reported problems. (Examples of family complaints included incidents when patients received medications late or needed to change rooms because of noise.) Patient falls accounted for 12 percent of events reported on shift coupons.
Why did the shift coupon generate more reports? “Nurses on the sharp end of health care can often tell you what caused an adverse event better than people in executive or administrative roles who are not on the floors day after day,” Dr. Kellogg says.
Differences in reporting
The article notes that when it came to patient falls, new skin breakdowns, new nosocomial infections and unexpected patient deaths, there was not a significant difference between the number of adverse events reported via shift coupons and traditional incident reports.
Why were problems like patient deaths nearly as likely to be reported on shift coupons as traditional hospital reporting systems? One hypothesis is that because high profile problems like falls and patient deaths involve the attention of more than one person, they tend to be regularly reported.
“The more visible the error is,” Dr. Kellogg hypothesizes, “the more likely it is to be reported.”
The shift coupon also asked nurses to identify the causes of adverse events. Nurses said the most common causes of adverse events were a lack of staff (37 percent), lack of communication (31 percent) and work overload (30 percent).
A broader range of information
As Dr. Kellogg’s study shows, there are some important differences between the type of data a tool like the shift coupon can collect when compared to the formal reporting process used by most hospitals.
“I was surprised about the number of patient and family complaints we collected, because these adverse events are often not stressed in hospitals to the same degree as other types of adverse events,” Dr. Kellogg says. She adds that additional research and quality improvement initiatives are needed on these types of errors.
Another difference? While shift coupons collect information on a broad range of adverse events, causes and demographics, the trade-off is that hospitals get fewer specific details about individual adverse events. However, Dr. Kellogg points out that the shift coupon provides a method of collecting trend data for a hospital, unit or specific adverse event.
“The shift coupon does not ask the health care provider to identify the specific patients and the medications per se,” Dr. Kellogg explains, “but it asks the health care provider to identify the occurrence of medication error and the causes. A hospital may not know the actual drug involved in specific medication errors, but the hospital will be able to identify trends of what’s going on in a unit or in the hospital.”
That’s critical, she adds, because hospitals need as much information as possible to target quality improvement initiatives. Without good information, they may be taking the wrong approach to improving patient care.
Edward Doyle is Editor of Today’s Hospitalist magazine.
For more information about or a copy of the shift coupon form used to collect information, contact Victoria A. Kellogg, PhD, CRNP, MBA