Compliance Corner, May ’23

Incident Reporting

The primary goals of incident reporting are to improve patient and workplace safety and to take the lessons learned to positively change policies and practices.  From here, preventative measures and interventions can be implemented to promote system wide, sustainable change. 

We want to ensure a safe and open reporting culture. The organization’s incident reporting system is in HealthDox and can be accessed by any employee who signs in to the HealthDox system, the reporting system includes a step-by-step process to complete, enables data analysis to be done in a prompt fashion, and includes reports that help us evaluate overall reporting throughout the system.  The goal is to employ a transparent, non-punitive approach to reporting and learn from adverse events or any identified unsafe conditions. 

Why do we want to report incidents?  1. To learn from incidents or near misses, to proactively look at our practices to see if system changes will improve patient and staff safety.  2. To analyze collected data to see where changes can be made to improve safety and care quality.  When done well, it shows safety hazards and guides the development of interventions to mitigate risks, thereby reducing harm.   3. This data analysis and trending also helps us move toward recognition and implementation of best practices.  4. Evaluating trends and root causes allows us to share data to help us decide what types of issues are occurring, where we may have spikes in occurrences, how we can reduce harm, and allows us to communicate these trends to the administrative team, regional team, program directors and field personnel for better awareness. 

Incident by Year
Id	Year	Incidents
0	2021	659
1	2022	1005
2	2023	230

In 2022, throughout the BHG organization, we had 1005 incidents reported by 75 locations.  Each of the 75 locations sent between 1 and 33 incidents throughout the year.  From 1/1/2023 to 4/5/2023 we have had 230 incidents reported.   A key takeaway from the data above is that we had approximately 40 sites who reported zero incidents for the entire year in 2022.  From the reporting perspective, this would lead one to believe we may be underreporting.  When we evaluate why we may be underreporting, we want to look at some common reasons and make sure these issues are addressed.   

1. Lack of access to the reporting platform:  HealthDox is our IR reporting platform and any BHG employee who signs into the system can enter an incident report.  The incident reporting process is one of the required topics of education assigned to new employees. 

2. Fear of reporting: We do not want to focus on a culture that simply looks at which rule was broken, who did it, what are the consequences associated with it.   BHG’s focus is a restorative culture where openly and honestly sharing mistakes made comes first and foremost. Human errors are going to occur.  The focus is not on who made a mistake and what are the consequences, but on how can evaluate the factors the led to the error, fix the system/process, and educate so the issues do not continue.  The origin of errors must be examined and discussed openly to bring about change. 

3. No clear understanding of what to report: The most important thing to remember is this.  If you feel like you should write an incident report, do it.  It is far better to have an incident report and not need it than to need it and not have it.  If you are not sure if you should write a report, you are welcome to drop an email to a member of the regulatory team for guidance.  The most common types of incidents to report are patient or staff injury or fall, medication error, community death of any active patient, impaired patient, medical emergency, confidentiality issue, patient to patient altercation, environmental hazards, and equipment failure.  

4. Reporting platform is not user friendly: The HealthDox reporting platform is a step-by-step process.  Questions are listed, many with drop downs for answers and you answer all of them in order.  When the IR is complete you save the report, and it will be reviewed by a member of the regulatory team if it is a general category incident report.  If it is a medication error, a member of the Pharmacy team will review the incident.  If more information is needed, one of the team members completing the review will email you with any other information required.   

I have yet to find an incident reporting platform that does not have an occasional glitch. The most important thing to remember in HealthDox when completing a report is to always remember to be sure you are signed in and your name shows at the top of the page before you start to enter your IR.  If you show up as a guest user at the top of the page and your name does not appear you will not be able to save the report. 

I hope this has been helpful.  We want to assure you that the administrative team is committed to a non-punitive restorative culture with a primary focus on system improvement, patient and employee safety, and collection of data to help drive system wide improvement.  A link to the adverse events and critical incident reporting policy (#709) is below. 

Policy 709