To meet its goal to nearly double the number of event reports submitted through its event reporting system between 2014 and 2017, Children's National Medical Center adopted a three-pronged approach to encourage staff to report, said speakers from the Washington, DC, hospital at the Institute for Healthcare Improvement's National Forum, meeting December 4 through 7, 2016, in Orlando, Florida. First, they improved accessibility to the reporting system to make it easier to report, said Lisbeth Fahey, MSN, RN, the hospital's executive director of quality, safety, accreditation, and emergency preparedness. For example, the hospital reduced by 50% the number of mandatory fields necessary to complete a report (to eight fields) and developed a mobile app for staff to quickly access the reporting system. Although entering data can be cumbersome with the app, "it's always good to offer [reporting] options," said Sonal Kalburgi, DO, MSHS, with the hospital's division of hospitalist medicine. Second, they took steps to ensure staff receive feedback about event reports. "The perception is that reporting makes no difference, but the reality is quite different," said Laura J. Sigman, MD, JD, who divides her time in the hospital's emergency department and the legal/risk management offices. In addition to sending e-mails to reporters alerting them to the status of their event reports (i.e., received, investigation in progress, report closed), the hospital is modifying its reporting system so staff will be able to log on and view text providing feedback about the event report. Additionally, managers can use the reporting system to generate weekly and monthly reports to provide feedback to staff about event reports. Third, the hospital fostered a "just culture," where staff are accountable for their actions but are not blamed, said Deborah Freiburg, MS, RN, NE-BC, director of medical nursing. With the support of the human resources department, the hospital developed a module to teach staff about its just culture decision-management tree, which encourages key decision makers to consider systems and organizational issues in the management of error. "We trained all hospital leaders [on the decision tree] and hardwired it into our policies and procedures," Freiburg said. As a result of these changes and others, event reporting has increased, and the quality of the reports is meaningful, said DiAnthia Patrick, BS, PharmD, medication safety coordinator. Summarizing the medical center's strategy, she said, "Make it easy and safe to report and show that reporting makes a difference."

HRC Recommends: To improve patient safety, adverse event reporting must be viewed as more than fulfilling regulatory requirements. In order for healthcare organizations to learn from adverse events and maximize patient safety, they must have a supportive, nonpunitive culture and a true accountability to deliver safe patient care. To reinforce just culture, both policy and practice for any reporting system should emphasize that valid feedback from staff on the organizational factors promoting errors is far more important and appreciated by management than any assignment of blame to individuals.