While Saskatoon Health Region’s Safety Alert System makes it fairly easy to report safety incidents, figuring out how and why they happened hasn’t been as straight forward.

Recently, a team of twelve people worked on a continuous improvement project to help streamline the process of reviewing the Region’s level three (harm) and four (serious harm) safety incidents and to ensure that patients, families and our care providers are aware of how we are addressing these incidents when they are reported.

This team recently worked on a continuous improvement project to improve the review process for the Region’s serious harm safety incidents.

This team recently worked on a continuous improvement project to improve the review process for the Region’s serious harm safety incidents.

Analyzing safety incidents is not exactly intuitive which is why the team wanted to focus on improving the preliminary review process and in-depth analysis of safety incidents.

“We wanted to build a reliable process with transparency and visibility to our patients, families and care providers affected by safety events and to build confidence in how our organization addresses our most serious safety incidents,” says Heather Miazga, Director of Surgical Services and team co-lead on the project. “We also wanted to clarify the responsibilities of operational and physician leaders assigned to a safety incident review and create some standard tools to support leaders in understanding all the contributing factors of a safety incident.”

The team, co-led by Alex Morgan, Director of Information Technology Services, identified a number of gaps that exist when a level three or four safety incident is reported. “There were no clearly defined processes for getting the appropriate documentation and contributing factors to review and a lot of confusion as to who is responsible for getting the process started,” explains Miazga.

To assist with this problem, the team came up with some work standards for anyone responding to level three and four safety incidents. This included some initial assessment guidelines with some prompts and guiding questions to ensure the person responding could get the appropriate information for follow up. The team also developed a standard form for the report and handover to the operational team which included a checklist for the director or vice president so that they can ensure nothing is forgotten when going through their mitigation and review process.

Throughout the project, the team discovered that when it comes making the initial call to the Safety Alert System, the direct care worker was not always sure about what to expect when they called or how they would be contacted for follow up. This would sometimes result in a delay in reporting. The team developed a tool to support staff in understanding the process after a report is filed so they know what information they need to share for follow up with the director or vice president reviewing the incident. Staff who tested the tool found it very helpful.

The team also developed a better process for patient disclosure. Before the improvement project there was no consistent method for keeping patients and families engaged, updated and informed throughout the in-depth analysis of their safety incident. “As it stands right now, the Region’s policy on disclosure is almost entirely about preparing for disclosure around the initial event and not as part of an ongoing process with the patient or family,” explains Jamie Herman, Client Representative. “What we worked on was creating a better ongoing disclosure process. Once the initial disclosure around the incident happens, the operational lead will connect with our Client Representative office and we will reach out to the patient and family in a more consistent fashion and continue the dialogue which will be guided by the patient and family’s preferences.”

There is still work to be done but Miazga feels these improvements will help ease the process of mitigating, reviewing and analyzing safety incidents. “Whenever there is a safety incident, there is a lot of emotion involved for patients and families, as well as employees,” says Miazga. “Having standardized tools and checklists in place can help those responding to level three and four incidents respect that emotional process, while at the same time allowing them to get the information they need to begin figuring out how and why the incident happened so that we can try and prevent it from happening again to someone else.”

To learn more about how safety leaders across the province are creating processes that will make it easier for patients, families, staff and providers to stop the line watch “Making Healthcare SAFER for Everyone- Safety Alert/Stop the Line System”.