• Am. J. Surg. · Jan 2020

    An improved patient safety reporting system increases reports of disruptive behavior in the perioperative setting.

    • Micah G Katz, Wendy Y Rockne, Ruth Braga, Stephen McKellar, and Amalia Cochran.
    • University of Utah Health School of Medicine, Department of Surgery, Salt Lake City, UT, USA.
    • Am. J. Surg. 2020 Jan 1; 219 (1): 21-26.

    BackgroundPatient safety event reporting systems are a mainstay in non-punitive reporting of near misses and adverse events. We hypothesized that an upgraded reporting system that included the ability to report positive behaviors would increase behavioral reports in the perioperative environment.MethodsWe performed a retrospective assessment of prospectively collected reports from the Patient Safety Net (PSN) event reporting system (2/2010-2/2015) and the RL Solutions RL6 system (8/2015-4/2018).ResultsUnder the PSN system, 0.8 behavioral events per quarter were submitted, compared to 7.4 behavioral events per quarter with the RL6 system. The average length of reports increased from 61 to 185 words. Reports were most often submitted by nursing staff (66%), and about attending physicians (36%). 22% of reports under the RL6 system were positive; 46% of these positive reports were about physicians.ConclusionAfter implementation of an upgraded reporting system that includes an option for positive reporting, the number and length of reports increased. We believe that a robust reporting system has contributed to a culture of safety at our institution.Copyright © 2019 Elsevier Inc. All rights reserved.

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