Reference no: EM132176308

Case Study: After a considerable investment of both money and time, executives at Leman Healthcare were delighted that the new incident-reporting at Leman was now fully operational. The incident reporting system had been deployed across the healthcare system; frontline and management staff, as well as physicians in both inpatient and ambulatory settings, had been trained and were able to use the incident-reporting system to access patient information, document adverse events, and report as required to senior management, risk management, and QI department. However, even with full system development, QI activities across the health system has not changed. The QI department had full access to the data warehouse that housed data collected through the incident-reporting system as well as data from the electronic health record and other information systems, yet QI staff members were apparently not using these data. Instead, QI projects continued to follow historical patterns involving laborious efforts to develop queries and reports rather than use the new system's immediate reporting capabilities to supply information for managers and to drive process improvement projects both locally and across the hospital system. Similarly, the potential for clinicians to use the newly accessible date was not being realized. Physicians were reluctantly compliant with requirements to use the incident-reporting system and documentation for reporting, but the general consensus seemed to be that the system was just a way to point fingers at the medical staff. Despite efforts from the senior management team to work individually with clinicians to educate and explain the importance of error and near-miss reporting that would provide information to reduce errors, these physicians continued to view the incident-reporting system as a punitive tool, as an opportunity for them to explore ways to improve their work.