Adverse Event Review

Concerned that you aren’t catching trends or don’t have a staff member with the right skill set for reviewing adverse event reports? Not sure which events rise to the level of requiring Root Cause Analysis or Common Cause Analysis? How can you share lessons learned to really drive change and improve patient safety?

As the Senior Analyst in Patient Safety for the Johns Hopkins Hospital and Health System, I reviewed all event reports, triaged them to ensure they were seen and addressed by the right people, and worked with teams to resolve issues and risks, as well as providing trending across the Health System. As a Director of Patient Safety at two other hospitals, I had oversight of the event reporting systems and sought new ways to share learnings from events in the most productive and proactive manner. No-harm/low-harm adverse events are often overlooked because high-harm events necessitate significant attention, time, and resources for appropriate resolution. However, taking the time to focus on no-harm/low-harm events (and staff observations of unsafe practices or situations) is the best risk-reduction strategy. Widely sharing the lessons learned and publicly celebrating ‘good catches’ are the best ways to gain staff confidence and reinforce that event reporting systems are an important learning tool – not a punitive tool.

Having reviewed tens of thousands of adverse event reports – from near misses to sentinel events – in numerous adverse event software packages, I have a thorough understanding of what to look for, how to categorize and trend, and how to effectively use that data to drive change and reduce risk.