How Reporting Hospital 'Close Calls' Helps Keep Patients Safe

March 08, 2018 7:00 AM

A transparent and team-based approach identifies problems and works to protect patients.


There’s no question that hospitals are designed to be safe spaces. Layers of procedure and trained professionals are in place to ensure that every patient receives the best care.

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But if a lapse in protocol or a near-accident occurs, health care teams take note — and, if needed, action — to help avoid future hazards.

Those incidents are known as “safety events.” And each one, no matter how small, is taken seriously.

“Anytime there is a concern from anyone in the system, we address it,” says Kathrynn Thompson, a patient safety program manager for University of Michigan C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital. “Everything gets investigated.”

Each case is different, but some have greater consequences. A patient could receive an incorrect dose of medication, for example — despite pharmacy verification, digital bar codes and several other safety checks.

Although that scenario is rare, the report would trigger a swift and thorough response: “We don’t want to be in the business of causing harm to our patients,” Thompson says.

No matter the size or scope of a problem, Michigan Medicine emphasizes honesty and cooperation among its staff to detect, solve and reduce problems.

Thompson explained several important points about safety incidents:

Every case is reviewed: Big or small, each report receives due process. “All incidents come through the same venue so we can look not only at the individual occurrence but also review events in aggregate to see whether there has been an increase overall,” Thompson says.

Staff teams “huddle” every day: Multiple standing meetings take place each day at Michigan Medicine hospitals. The huddles allow staff of all specialties and seniority to share and discuss concerns about patient safety or process. Any issues are advanced to proper teams for review.

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Many people are involved: Once a safety incident is in motion, the inquiry involves multiple departments — including the hospital’s patient safety office, department heads, hospital administration and patient and family advisory committee members. “It takes a lot of people to understand what happened and determine effective plans for avoiding future incidents,” Thompson says.

Serious incidents get immediate and concerted attention: Although minor or near-miss reports are recorded and addressed, critical issues receive deep scrutiny and proactive response. Says Thompson: “We will always get to the root cause with a robust action plan to ensure all systems are improved.”

Changes do result: Recently, a Mott staffer cited delays in getting incubators to the general care department; a simple solution — ordering infant heating pads — was found. And, last year, a patient’s plug-in toy that began smoking led to a hospitalwide review of toy safety guidelines.