Review of Effective Use of the Departmental Electronic Occurrence System for the Patient Care Related Safety Events. A CMC VAMC Experience

Abstract

Abstract Introduction/Objective Electronic patient safety event reporting (e-reporting) is an effective mechanism to learn from errors and enhance patient safety. The Pathology and Laboratory Medicine (P&LMS) has established an electronic occurrence reporting (EOR) program to detect occurrences in patient results prior to the release of results, procedures for the documentation of corrected results that have been released, and any deviation to standard operating procedures. Patient safety and its monitoring is improved by using the EOR reporting system in which healthcare workers can document and learn from incidents, and thus prevent potential medical errors. The authors explore the use of the EOR in the calendar year 2021 and its effective use. Methods/Case Report The EOR is available to all the employees of P&LMS. This EOR allows the recording of all information pertinent to the occurrence (including pre-analytical, analytical, and post analytical issues) and a variety of issues (i.e., safety events, notifications, recalls, correction of released results, changed, results, or any unexpected standard operating procedure deviation). The section supervisor will initiate an investigation including root causes and outcomes of the occurrence and propose corrective action, recommendations, and follow-up in the Occurrence Detection Database. This is also reviewed at the quality management meeting and by the sectional pathologist director. For quality assurance review, the EOR’s usage for January 1st, 2021, to December 31st, 2021, was reviewed. Results (if a Case Study enter NA) The EOR successfully allowed the full documentation of all 870 reported occurrences during the study period in an organized fashion allowing appropriate tracking and investigation for quality improvement. All reported occurrences were handled appropriately with organized data to ensure quality assurance and improvement. Conclusion The EOR is a highly effective, successful program in terms of monitoring and assisting in ensuring timely action is taken in real time for patient care. Electronic reporting and documentation of incidents should be well supported by continuous staff training, help, and feedback. The ERO plays an important role in the maintenance of Veteran Affairs’ position as a High Reliability Organization (HRO).