Kettering Health is committed to Just Culture and Patient Safety. Through Press Ganey’s Zero Harm initiative, we have a goal of reducing Serious Reportable Events (SRE) 80% by 2025. 

As a refresher, we’re working toward the following goals in 2023:

• Reducing the Serious Reportable Event (SRE) rate by a threshold of 15%, target of 20%, and stretch of 25%.
• Increasing Great Catch submissions by a threshold of 10%, target of 15%, and stretch of 20%.
• Increasing safety event reporting by a threshold of 5%, target of 10%, and stretch of 15%.

Why is safety reporting important? 

From 2020 to 2022, safety events reported decreased from 22.31 to 19.05 per 1,000 patient days.   

Safety event reporting is fundamental in improving patient safety. It is a key indicator of the overall culture of safety at Kettering Health. A safety event can occur 8-10 times before serious harm reaches the patient. By reporting early and often, we can fix an issue before serious harm reaches the patient.  

An error is almost never the fault of a person. Errors generally occur because of system and process issues. Learning about safety concerns in advance of harm allows us to fix systems and processes.     

What should you report?

Submit a safety event for any deviation that occurred outside of the expected procedure, guideline, standard of care, policy, or rule. When in doubt, report.   

See the Incident/Occurrence and Serious Reportable Event Reporting policy for more information.

How to report 

On the intranet homepage under the Quality and Safety tab, select SAFE Event-Patient or Visitor Incident link to report a safety event.

Steps taken after you report

Every event that is entered is reviewed by the campus Quality and Safety team. The level of investigation of the event depends on the level of harm. 

Changes to SAFE based on your feedback

Changes were made to SAFE (Midas) based on employee feedback in the Culture of Safety Survey and rounding.  

• We heard that it takes too long complete the form.
  • We set a goal of an average of 5 minutes or less to complete the form. To achieve that, we reviewed each question to determine if the information was necessary at the time of event entry or if it could be found during the event review/investigation. Questions were eliminated if they could be discovered during review. 
  • The forms were standardized so the look and language are consistent. We also moved to tabs to eliminate the scrolling.
• We heard that event reporting can feel like a black hole—you aren’t sure if anything is done with the event report you submit.
  • Each event is reviewed by the campus Quality and Safety leader. We are developing a process to provide direct feedback to the person entering the event on the outcome (as relevant).  

Form entry homepage changes

• Combined Medication/IV Error with Adverse Drug Reaction (Medication/IV Related Event). 
• Combined all invasive events into one form (Procedure/Surgery/Treatment).  
• Combined noninvasive events into one form (Diagnostic Test/Lab Event).  
• Disruptive Behavior should be used for physicians, staff, patients, and visitor behavior. 

Great Catches

Thank you, Emilie Anderson from Kettering Health Dayton, for your Great Catch. While performing a dispense check of a nifedipine dose, Emilie noticed that three x 90mg tablets had been used instead of three x 30mg tablets to make a single 90mg dose. The technician had prepared the dose, but had not scanned all the tablets, thus making the dispense prep appear correct and without warnings. Emilie’s attention to detail saved a potential three-fold overdose.

Thank you, Megan from Kettering Health Dayton, for your Great Catch. While reviewing the isolation patient list, Megan found three patients who were being worked up for infections but did not have blood cultures ordered on admission. She reached out through MatchMD to the hospitalists admitting each patient. The hospitalist believed blood cultures were done prior to admission in the emergency department. Blood cultures were performed and identified possible bacteremia present on admission.

Medication safety: A tale of two medication events

Nearly everyone in healthcare has witnessed, heard of, or experienced a medication error. Errors happen. Similarly, nearly everyone has witnessed a near-miss or Great Catch type of event. When we zoom out from all the details of the events, we realize that both medication events and near-misses are the same tree, just at different stages of development.  

First, you have the near-miss, Great Catch, or what we might call the precursor event. Take the example of a patient who is admitted to the ICU and placed on a custom IV fluid by a provider when there is already a premixed product available. The compounded product is verified by the pharmacist, prepared by a pharmacy technician, given by the nurse and this goes on for several days. However, when the patient was next reviewed by the clinical pharmacist in the ICU, they notice that the order doesn’t look like typical orders for this product. On further review, they notice the problem and correct the order. That’s a Great Catch! 

At this point, the story can go one of two ways.

The first is that we congratulate the clinical pharmacist for their diligence. We explain what happened to the providers, nurses, pharmacists, and pharmacy technicians involved. We tell them that diligence is key, always use the five rights, pay attention to details, and so on. No one was hurt, the patient goes home, the crisis is averted.

Or is it?

The patient comes back to the ICU a few weeks later. The provider on duty recognizes the patient, the situation, and decides to put them back on the medications that had worked previously with a slight change. In modifying the order, the provider accidently orders sterile water. The pharmacist misses it. The pharmacy technician misses it. The nurse misses it. The result? Serious irreparable harm.  

What could have been done?  

At this point, we have our second option; what should have been done. This is the chain of events had a SAFE report been placed by the pharmacist who caught the error. 

During review, the Safety team determines that there is an issue with the order that was used, and that order was corrected. It was also determined that there were better ways for the provider to have ordered this medication, so changes are made to the provider’s preference list.  

So, the patient comes back in a few weeks after the initial event. The provider gets the correct record. Now, the order even routes to the Omnicell, so there’s no wait. The patient recovers and goes home to their family.  

The moral of the story is: Unless the underlying problem is corrected, it will happen again.