Patient Safety

SS 34 - Patient Safety

249 - High Volume Incident Learning System Use is Associated With Durable Improvement in Patient Safety Culture Over 5 Years

Wednesday, October 24
8:25 AM - 8:35 AM
Location: Room 008

High Volume Incident Learning System Use is Associated With Durable Improvement in Patient Safety Culture Over 5 Years
P. Hartvigson1, M. Nyflot1, A. S. Kusano2, L. Jordan2, M. B. Spraker1, A. Kim2, R. P. Ermoian3, G. M. Kane2, and E. C. Ford4; 1University of Washington, Department of Radiation Oncology, Seattle, WA, 2University of Washington, Seattle, WA, 3University of Washington, Radiation Oncology Department, Seattle, WA, 4University of Washington Medical Center, Seattle, WA

Purpose/Objective(s): Incident learning systems (ILS) require substantial time and effort to maintain and risks staff burnout and ILS disuse. Understanding the permanence of ILS benefits to safety culture and the relationship between staff ILS engagement and safety culture are important considerations for resource allocation for safety initiatives. Here we assess the durability of ILS-associated safety culture improvements and ILS engagement at five years.

Materials/Methods: Prior to initiating the ILS in 2012, a survey assessing patient safety culture was sent to all staff to establish a baseline. The survey draws from the validated AHRQ Hospital Survey on Patient Safety Culture. The same survey was collected annually for the subsequent five years through 2017. Key aspects of safety culture, including overall patient safety grade, were analyzed using chi-square test to compare baseline rate of positive scores (4-5 on 5-point Likert scale) to the post-ILS 5-year average. ILS engagement was measured by self-reported number of ILS entries submitted by respondents in the previous 12 months.

Results: The annual safety culture survey response rate was ≥68% each year (range 68-81%). High-volume reporting was sustained over five years (4673 reported events; average of one ILS entry per patient). Significant increases in positive responses pre vs post-ILS were observed in responsibility and self-efficacy (p < 0.001), feedback (p < 0.01), teamwork (p<0.01), and open communication and punitive concerns (p = 0.02). The percent awarding the department an “excellent” safety grade increased from 16% to 28% (5-year mean). Overall patient safety grade of good or excellent was significantly improved (69% vs 85% 5-year mean, p = 0.03). The percent of self-reported ILS engagement increased significantly (p < 0.001).

Conclusion: Comprehensive high volume incident learning is associated with significant improvements in patient safety culture and improved ILS engagement over 5 years, offering further evidence for the broader adoption of such safety initiatives by other institutions.

Author Disclosure: P. Hartvigson: None. M. Nyflot: None. A.S. Kusano: None. M.B. Spraker: None. A. Kim: None. R.P. Ermoian: Employee; Neighborhood Healthcare. E.C. Ford: Research Grant; National Cancer Institute (NCI). Board of directors member; AAPM.

Pehr Hartvigson, MD

Disclosure:
Employment
University of Washington Medical Center: Resident physician: Employee

Presentation(s):

Send Email for Pehr Hartvigson


Assets

249 - High Volume Incident Learning System Use is Associated With Durable Improvement in Patient Safety Culture Over 5 Years



Attendees who have favorited this

Please enter your access key

The asset you are trying to access is locked. Please enter your access key to unlock.

Send Email for High Volume Incident Learning System Use is Associated With Durable Improvement in Patient Safety Culture Over 5 Years