Purpose: Our goals were to improve our reporting of workflow errors and near misses by making it easier and faster for staff to report them. We also wanted to have quick access to the data in ways to filter, report it and act upon it. We needed to clarify what incidents would be reported in each system. From there we felt we could have more data to act upon and make improvements to workflows. Our big picture objective was to enhance the culture of reporting and making changes with that information.
Methodology: UPMC enterprise uses an established reporting system that cannot be eliminated because it automatically reports required items to the state. A small workgroup looked at items not needing to be reported to the state and created a secondary incident learning questionnaire to capture those items. We created a Microsoft Form to collect information on near misses and improvement suggestions. This is called the great catch form. In the form we focused on which step in our standardized process the error happened and when was it caught. It also allowed for a kudos to be given to a staff member for catching the error or for someone that helped fix it. We decided to trial in the hub of our network. The quality team sent results to the department leaders every other week outlining trends and the department eventually created a committee to review the numerous entries. This great catch committee looked for trends and concerning items to address, then proposed workflow changes or re-educations to reduce recurrences. After success was realized a slide deck was created to promote the use of this great catch form and presented across all staff radiation oncology network meetings to ask for other sites to expand the trial.
Results: The use of the Great Catch Form for near misses has increased reporting significantly. The trialing department had a high of 22 near misses reported in previous years with the enterprise incident learning system and have increase to an average of 29 per month. From the increase in submissions, we have learned our confirm simulation checks catch and physics 2nd checks are catching most of these misses.
Conclusions: We have already seen an uptick in reporting from our second site as well but have only been trialing for a month. One area of concern, as we continue our roll out is ensuring we have engagement of staff and leaders to use this system. In our trial site we had Travis as a very dedicated champion to encourage its use and educate staff. Change is hard but with the results we are seeing there is great value in continuing to grow this effort to enhance our culture of improvement.
