36 hours ago At Brigham and Women’s Faulkner Hospital, patient safety is always a top priority and it’s an area in which we can always improve. That’s why “Highest Quality, Safest Care” has been identified by hospital leadership as a key goal for 2018. Recent changes made in the Laboratory highlight just how impactful it can be when staff report patient safety issues in RL Solutions, BWFH’s ... >> Go To The Portal
The interventions, improvements and trends can then all be reported graphically in dashboards. By partnering with our clients and legislative bodies, RL is able to provide software solutions to all of the different vectors of an adverse event. This will help our healthcare teams make data-driven decisions and subsequently improve patient safety.”
Reporting in RL6 Risk strongly supported and encouraged Public Health Examples • Wrong dose, or wrong medication or vaccine, but noticed just before administration. • Someone leaning over the counter to read what is on your screen but you quickly change your screen before they can read personal health information.
RL Solutions reports also help trend patterns of problems, identify volume of impact and serve as documentation of incident follow up. Why don’t people report? There can be a perception that reporting will create a punitive response to errors that are reported. Some people worry that they will be “written up” based on errors or problems reported.
Additionally, staff can request written feedback within the reporting form, and staff are encouraged to ask their Director or the Patient Safety Department for an update on an issue they submit. Who can write an RL Solutions report? Any staff who witnesses an event that affects patients’ safety can submit that event.
RL Incident Reporting. Page 5. The Medical Device Reporting and Recall form is used to report incidents involving equipment, failed medical devices, and recalls.
RL Hospital Abbreviation1RLHealth, Healthcare, Diagnosis1RLHealth, Healthcare, Diagnosis1RLTherapy, Treatment, Medical1RLMedical, Health, Healthcare1RLMedical, Health, Healthcare8 more rows
RL Solutions is a global company that designs comprehensive healthcare software for patient feedback, incident reporting & risk management, infection surveillance, claims management, peer review and root cause analysis.
generic Control Banding risk levelA generic Control Banding risk level (RL) matrix as a function of severity and probability.
Noonan syndrome (NS): A multifaceted genetic disorder characterized by a series of birth defects (congenital malformations) including dysmorphic (malformed) facial features, short stature after birth (postnatal growth retardation), webbing of the neck (pterygium colli), caved-in chestbone (pectus excavatum), ...
Why should safety events be reported into RL Solutions? A safety event helps identify vulnerabilities and safety gaps within systems that allow errors to occur that can impact patients. Safety reporting prompts corrective action to improve care and patient safety.
Despite its flaws, safety event reporting is an important tool for identifying system hazards and aggregate data, and sharing lessons within and across organizations. Systems can share known fail points in care, which allow other systems to identify that as a potential risk within their own organization.
Duty of candour means every healthcare worker must be open and honest with patients when something goes wrong with their treatment or care. It is a legal obligation that care providers must inform the people affected by the incident, offer reasonable support, provide truthful information and a timely apology.
A patient safety incident is any unplanned or unintended event or circumstance which could have resulted or did result in harm to a patient. This includes harm from an outcome of an illness or its treatment that did not meet the patient's or the clinician's expectation for improvement or cure.
A risk review process or a risk assessment meeting is a crucial part of any project. Having this meeting will address the strategy behind risk management so that the project manager and the team responsible for the project's success can come together to handle any associated risks before they happen.
The aim of the risk assessment process is to evaluate hazards, then remove that hazard or minimize the level of its risk by adding control measures, as necessary. By doing so, you have created a safer and healthier workplace.
R. Risk level = L multiplied by S. 1 or 2 Low risk. 3 or 4 Moderate risk. 5 to 9 Very high risk.
Having the phlebotomists carry a Vocera has also improved communication and therefore efficiency. “The clinical staff can now communicate with the Phlebotomy team immediately,” Ambacher explains. “That means there’s a decrease in the response time for patients with an immediate collection need.”
Phlebotomists now carry Vocera, a device that allows for direct communication with the nurses on the unit. “Adding more staff and having them come in earlier has allowed for optimal coverage,” says Laboratory Director Rachel Ambacher, MS, MT (HEW).
A patient-related event or circumstance that resulted in an unintended and undesired outcome such as an injury to a patient and/or damage to or loss of equipment or property It’s an opportunity to support the development of processes and structures that prevent a similar event from reaching the patient.
The reporting system has changed to improve the efficiency and effectiveness of the process. There are many ‘delays’ in the current process when the form is sitting on a managers/directors/quality desk. A key goal is to reduce delays to help improve the quality and safety of care.
Reporting in RL6 Risk strongly supported and encouraged
The Patient Safety/ Risk Management Department reads all submitted reports daily. Directors are also automatically notified of all reports filed on their floor or unit. Depending on the type of event, other groups will assist in the review process. For example, for medication events, the Pharmacy Director and Managers provide additional reviews. Senior Leaders read most events weekly in summary reports so that they have awareness of the issues that are impacting patients, families and staff.
RL Solutions is Brigham and Women’s Faulkner Hospital’s safety reporting system. Below, the Patient Safety team answers frequently asked questions about the program. If you have additional questions about RL Solutions or would like training on how to report, contact Caitlin Parrott at extension 7679 or cparrott@bwh.harvard.edu or Chris Haffenreffer at extension 2450 or chaffenreffer@bwh.harvard.edu.
Some staff don’t report because they are unsure that reporting makes a difference. They may have worked in other places where reporting goes into a “black hole” and it feels like a waste of time to report issues as a result. BWFH has created a reporting system based on our culture of high reliability and continuous learning. We use reports to work on system problems and to improve patient care. Every report is read by leaders within the hospital at the local and administrative level. Our goal is to review and resolve issues within two weeks. Many of the improvements are highlighted in our weekly newsletter Last Week in Patient Safety. Additionally, staff can request written feedback within the reporting form, and staff are encouraged to ask their Director or the Patient Safety Department for an update on an issue they submit.
However, in Just Culture, we analyze the hospital systems that surround and influence the event, as well as the choices people made during an event. This allows us to stay away from blame and focus our efforts on building a system that supports employees providing the safest and highest quality care. Sometimes reporting will help us clarify that a group of staff need more education on a particular issue or that we need to make changes to existing policies.
The icon is called “Safety Reporting BWH.” You then select the icon that best fits the event, fill in the fields with a green asterisk*, which are the mandatory fields, to the best of your knowledge and click “Submit.”
You do not have to be directly involved in the event to report. Some staff report for each other, particularly if one of the team needs to remain focused on the care of the patient. Events that affect staff safety should be reported as well.
CLINICAL SURVEILLANCE - Covid-19 - Creating Reports COPYRIGHT © 2020. ALL RIGHTS RESERVED. March 26, 2020
CLINICAL SURVEILLANCE - Covid-19 - Creating Reports COPYRIGHT © 2020. ALL RIGHTS RESERVED. March 26, 2020
Reporting potential risks and adverse events should lead to change, which would improve patient outcomes and at the same time, lower the cost of care. Focusing on quality of care improves patient outcomes and can drive costs down, which is something positive that we can all stand behind.”.
Medical Interactive sells to hospitals and other healthcare facilities and, since their educational materials are available on their website, many doctors and medical professionals obtain them directly.
Tallahassee Memorial Hospital (TMH) is a 772-bed facility with 3,500 employees and 500 medical staff members. Judy S. Davis, corporate risk manager, comments, “TMH uses the Clarity Healthcare Portal to document safety events throughout our entire facility, including the main hospital, behavioral health care, TMH rehabilitation, free-standing emergency center, family medicine program, as well as our outlying physician practices. The portal is web-based; readily accessible on our internal intranet by all colleagues and medical staff; easy to use with drop-down screens; integrates with our electronic health record to download demographic, coding, and diagnosis-related information; gives us real-time notifications; and provides enhancements based on needs as decided by the users.”
RiskQual Technologies in Pembroke Pines, Florida, was born out of the need to produce incident reporting tracking tools for healthcare facilities. “We used to provide services to hospitals in tracking their incident reports, claims, and litigation,” recalls Estee Wichterich, president of RiskQual. “Over the past 13 years, we’ve been enhancing our system, and it now includes incident reporting, claims management, complaints and grievances, and worker’s comp as well as quality events, peer reviews, and quality chart reviews. It’s a comprehensive, integrated system that allows any healthcare facility to track this data efficiently and effectively.”
Adverse event reporting and analysis can be very data intensive. Hazan comments, “We help our customers to make it as easy as possible and advise them not to collect data that they don’t need. Different events require different pieces of data; don’t collect anything that is irrelevant.”
The Joint Commission and the Centers for Medicare and Medicaid Services mandate that facilities have a way to track adverse events. Some states also have reporting requirement for certain types of adverse events. “I think a lot of this grew out of the advent of healthcare risk management in the mid-1970s,” notes Anna Marie Hajek, president and CEO of Clarity Group, Inc. “It was about understanding what could be a potential professional liability claim. You wanted to track incidents to enable you to better understand a potential event that could end up in a claim.”
Healthcare is highly regulated , and facilities have to do more and more data trending and analysis. “The change has been not just to have a tracking system but something that can ultimately reduce patient harm and cater to ongoing patient safety,” Wichterich says.
If you notice a service interruption with the RL6 system, you should first check the RL6 Hosting Status page to see if “EASTERN Time Zone” is impacted. And if impacted, then be assured that the RLDatix team is aware of the issue and working on it. You can monitor the incident progress via Statuspage or subscribe for incident email updates.
RLDatix communications including notice of outages related to “planned maintenance”, “emergency maintenance” and “unplanned service interruption”, as well as status updates and incident resolution will occur via Statuspage. Once the issue is resolved, RLDatix will also leverage Statuspage to share root cause once an investigation is complete.
Users with a valid login ID for RL can receive reports on a scheduled basis (i.e. daily, weekly, monthly, quarterly or annually. ) Reports will be sent automatically from RL via email. The message will contain a PDF copy of the report as well as a hyperlink to open the report within RL.
If you have RL6 Risk questions, please contact: or (204) 926-1070
The Report History is a list of recently run reports in Report Center, which includes saved and unsaved reports and any revisions. This is especially useful for being able to access a report you previously created or edited but did not save it. Report History can be accessed from the Report Toolbar or the Recently run reports link in the Report Management panel.
To search for reports: 1. In Report Manager, click Search all reports from the Report Management panel. 2. Enter your search criteria. 3. Click Search. The matching records are displayed.
Recently run reports: Displays a list of recently run reports, which includes saved and unsaved reports. This is especially useful for accessing reports that were previously created or edited, but not saved. This list is cleared with the Clear History button.
Move to – Moves the selected report to a different folder
The Report Manager is a tab in the Report Center where users can find existing reports and access report creation tools.