Closing the Loop: Follow-up and Feedback in a Patient Safety Program

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Article-at-a-Glance

Background

As health care organizations establish patient safety agendas, attention has focused on creating less cumbersome systems for reporting errors. However, experience at Brigham and Women’s Hospital (Boston) suggests that more emphasis needs to be placed on what happens after a report is submitted.

Follow-up and Feedback

Follow-up includes prioritizing opportunities and actions, assigning responsibility and accountability, and implementing the action plan. Feedback entails (1) follow-up to those who report issues and (2) communication to the hospital staff and clinicians about events and actions taken. Responsibility and accountability for improvements need to be assigned by senior administration to hospital leaders who can effect the needed changes. Hospital leaders, not just the members of the patient safety team, must own these changes or improvements. Events that require follow-up action are brought to the attention of risk management and the patient safety team through several mechanisms, including voluntary reporting of adverse events through a computerized safety reporting system, root cause analyses, and Patient Safety Leadership WalkRounds™.

Discussion

Developing and maintaining a systematic method for feedback represents more of a challenge than the completion of any single recommended action item. However, it is the feedback to the reporter that perpetuates the influx of information and closes the loop. Developing the information-tracking database has made providing feedback easier and more reliable but significant effort is required to keep the database current.

Section snippets

Follow-up and Feedback

Follow-up includes prioritizing opportunities and actions, assigning responsibility and accountability, and implementing the action plan. Feedback publicizes actions taken based on comments received to the persons who provide the specific reports or comments and to all levels of personnel.

To achieve robust follow-up of identified safety issues, responsibility and accountability for improvements need to be assigned by senior administration to hospital leaders (such as division chiefs or vice

Discussion

It is important to emphasize that the follow-up and feedback processes described in this article have been continually modified during the last three years. Assigning accountability has been one of the patient safety team’s biggest challenges; we have had numerous discussions with senior leadership to determine which leaders are to be held accountable for various issues, and we continue to refine expectations for how rapidly closure on issues needs to occur. For example, we had initially

Summary

Patient safety programs must systematically ensure that safety issues are followed-up in a timely manner, with the appropriate accountability, to ensure that potential harm to patients is minimized. In addition, feedback to reporters, senior leadership, and the entire staff is critical for the creation of a culture of safety. Communication and tracking tools, such as those described in this article, can help facilitate these processes and strengthen the overall safety culture.

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