Adverse Events: Recognizing, Reporting, Analyzing

October 23, 2015 Stephanie Radcliffe

The following is an excerpt from an article written by Tom Inglesby that originally appeared in Patient Safety and Quality Healthcare's Sept/Oct issue. To read the full article, please visit the PSQH website.

Incident reporting is only part of the approach to preventing adverse events. Reporting an adverse event, incorporating more analytical modules, such as a peer review or a root cause analysis to better understand the adverse event management side—those are the traditional methods.

"That’s how we’ve done it in the past, and those approaches will remain critical to preventing adverse events, but the exciting thing this year for us is proactive, real-time surveillance," says Mike Etzinger, vice president of marketing for RL Solutions in Toronto.

"The idea is to get ahead of the event rather than just doing a great job of managing the event once it occurs. Look for those triggers or indicators, in advance, which might prevent an adverse event from happening."According to Catherine Lathem, vice president for product management, “Risk Register is one component of it, a new module that we just released in February of 2015, which helps to log, assess, and prioritize potential risks as well as track initiatives to minimize those risks."

"The second part would be our risk surveillance component that takes real-time feeds from our lab, ADT, pharmacy, surgery, and medical records modules and looks for indicators that would identify, for example, potential sepsis or readmission, based on a particular surgery. It’s really bringing the critical data to the forefront, because risk managers today just have so much information to weed through."

"What we’re trying to do is to find that critical clinical and administrative data that might provide a risk manager, quality director, or someone in patient safety a broader view of what’s going on in the hospital in a real-time environment.”

She continues, "We filter that information based on what you want to see because the feeds are so data-rich. We work with the management team at the facility to really understand what, specifically, they are looking for." 

The parameters are set upon implementation. "They would determine if they want to know readmissions based within seven days, or based on 30 days, or readmission with a potential surgical site infection," Lathem notes. "They would set all those parameters. Then they would be alerted through an email alert or a pager alert, or it would be loaded onto a dashboard. We feel that the dashboard alleviates some alert fatigue."

"We start off with what we’re calling our tile wall, or our info center. You have icons on a wall, similar to all of our products, and they would tell you a raw number. Then, when you click on that, it would bring up either the report, or the file list, or the patient record, whatever is the pertinent information associated with that tile."

Etzinger adds, “We’ve gone with a consumer approach to the data entry experience. If you look at RL6, it has the interface that you would see on a smartphone, so it’s something that’s familiar to the user and allows them to get in and get out as quickly as possible with minimal training."

He adds, "While voluntary incident reporting after an incident will always be a critical component to any risk management initiative, risk surveillance serves to augment voluntary reporting by automatically surfacing information that might prevent an incident from happening in the first place."

Learn more about RL's Risk Surveillance solution here!

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