Readiness

Consider adjusting your current reporting process or design one:

• How does a patient or staff member report a problem?

• Who collects the information? How is it collected and recorded?

• What information is collected/recorded?

• Who needs to be involved in an immediate conversation?
• Who is responsible for making immediate changes (e.g. removing faulty equipment, stopping administration of incorrectly-labeled medications)? Keep track of staff members and others involved in the event who can later provide more in-depth information for analysis.
• Who will gather a team to analyze the event? Conducting a root cause analysis of an adverse event or near miss is a critical step in preventing it from happening again.
• How will you report the event externally, if applicable? Many serious events involving patient harm must be disclosed to state and/or federal health authorities.
• Who will communicate with patients and/or their families as well as to colleagues when a serious adverse event has occurred? Who will support staff members following the event?

• Patients and families can provide valuable insight into a harm event and often appreciate the opportunity to give feedback.
• Discuss how your office will provide a forum for patients and families to express concerns and how you will let them know that you are open to their comments.
• Be sure this process includes:
  • a way for patients to speak to a safety contact person,
  • a way to document the concern, and
  • a way to make sure there is follow up.
• Consider more regular mechanisms for patient input, such as suggestion boxes, surveys, or a dedicated patient liaison.

• Communicate with every staff member about expectations for how to report concerns and what should be reported, including close calls, adverse events, and problem areas.
• Similarly, communicate about expectations for how staff will respond when something goes wrong. Do not wait until something goes wrong to prepare.
• Consider including patient representatives on planning activities or safety initiatives.
• Use existing huddles or organize specific ones on safety to gather staff feedback and concerns.