Publication Date
1-16-2025
Journal
BMJ Open Quality
DOI
10.1136/bmjoq-2024-002880
PMID
39824526
PMCID
PMC11867619
PubMedCentral® Posted Date
1-16-2025
PubMedCentral® Full Text Version
Post-print
Published Open-Access
yes
Keywords
Humans, Patient Safety, Surveys and Questionnaires, Safety Management
Abstract
BACKGROUND: Despite wide adoption in the healthcare of safety event report (SER) systems, there is a paucity of unified structures for prompt analysis and action while retaining reporter confidentiality. We used a synesis framework to change siloed reviews of safety reports to a comprehensive appraisal of quality, safety, productivity and reliability to facilitate interventions.
METHODS: After a needs assessment survey, we launched serial plan-do-study-act cycles to (1) enhance teams' ability to access SERs, (2) facilitate regular multidisciplinary review of SERs to identify actionable opportunities, (3) allocate action priority using failure mode and effects analysis, and (4) launch actions and summarise data. Team of Teams model allowed for empowered execution. Measures included process-completion of review, team engagement, proportion of 'open' (those without action plan) reports within 1 month of filing; outcome-number of actions launched and completed, dissemination of actions and postintervention survey results; and balancing-resources invested.
RESULTS: 26 multidisciplinary leaders reviewed 3175 of the 3406 total reported SERs across four clinical units over 18 months. The proportion of reviewed to total SERs increased significantly from the first 6 months (75%) to the second 12 months (99%) (p
SUMMARY: We successfully implemented a sustainable process to comprehensively review, prioritise and act on SERs in our large institution and facilitated safety interventions using a synesis framework.
