Problem: To improve error reporting so as to increase patient safety in a health care environment in which many barriers to reporting exist.
Setting: Baylor Medical Center at Grapevine, a 104-bed hospital in Northeast Tarrant County that is part of the Baylor Health Care System.
Strategies for improvement: Partnering with DoctorQuality to provide a consolidated, Web-based form for error reporting, online education, and a risk analyzer, complemented by efforts toward cultural change including staff training, encouragement of feedback, and the use of financial and non-financial incentives to report errors.
Effects of change: After implementing the system, the number of events reported increased 250% to 500% costs for data collection, analysis, and management decreased by dollar 25,000 to dollar 35,000 annually; and the time required to track errors and make improvements was reduced 25% to 50%. Further, managers and staff were very satisfied with the system, ranking it >4 on a 5-point scale.
Conclusion: The institution's partnership with DoctorQuality to create a single Web-based form for error reporting was successful in improving efficiency and ease of access in reporting. Further, the institution was successful in creating a new organizational culture around errors. The success was due in part to strong leadership, collaboration of multi-disciplinary staff, the ease of use of the system itself, and the effective educational, motivational, and communication mechanisms used.