1/18/2002

Nonpunitive Policy Improves Error Reporting

Donna Young

A little over a year ago, Childrens Hospital Los Angeles instituted a nonpunitive policy for hospital employees who report medical errors and events that nearly resulted in errors.

Carol Taketomo, Pharm. D., pharmacy manager, said the policy, which applies to drug errors and "near misses," has created an environment in which employees are "much more comfortable reporting problems."

"There is no reluctance to talk about it anymore," she said. "Because we have been focusing so much on medication errors, people are not shy about talking. When they know nothing is going to be placed in their employee record, they are more willing to discuss and bring up issues."

Taketomo said the policy has been a "process of evolution" that began about four years ago when she and some of her colleagues attended a conference by Boston-based Institute for Healthcare Improvement.

"I had been tracking medication errors and trending information for a long time, but the seminar helped to get things off the ground," she said.

For two years, employees at Childrens have been able to submit anonymous accounts of medical errors by describing the events on a note and placing it in a drop box.

The reports obtained from the drop boxes have increased the hospital’s number of reported errors and near misses by five times what had previously been reported, Taketomo said.

"Five to eight years ago, errors were something to sweep under the carpet. But you don’t know you have a problem unless you look under the carpet," she said.

The anonymous-reporting program, Taketomo said, led to the volunteer nonpunitive-reporting policy now in place.

Under the nonpunitive policy, the hospital has had the opportunity chance to explore more areas for improvement, Taketomo said.

"On a monthly basis, we coordinate all of our information in which issues have been brought up, and then we brainstorm on how we can improve," she said.

Providing timely feedback to hospital employees and letting people know that their suggestions are important creates an avenue for communication, Taketomo said.

"And you have to show a willingness to follow up and try some of those suggestions and monitor the effectiveness," she said.

One such suggestion led to the hospital designing a better way to document the use of patient-controlled analgesia (PCA).

"We had a policy in place for someone to double-check the concentration levels [in the PCA syringes], but no place on the [nurses'] flow sheet to document that they had actually completed that process," Taketomo said.

The hospital designed color-coded stickers that are placed directly on the PCA syringes, she said. After an employee has followed the directive prompt on the sticker, that person removes the sticker and places it directly on the flow sheet.

"It has been very effective," Taketomo said. "And this was a suggestion that came from someone on the frontlines."

Taketomo said the hospital would not have been able to put the nonpunitive policy in place without the collaborative efforts of all of the employees.

"Pharmacy alone cannot move the mountain," she said. "It takes everyone getting on the boat and going in the same direction. And when you have people that truly believe in performance improvement, what you get from it is tremendous."


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