Event Reporting Web-based Portal
Rahul K. Shah, MD, George Washington University School of Medicine, Children’s National Medical Center, Washington, DC The Academy, via the Patient Safety and Quality Improvement Committee, is eager to provide membership with quasi real-time reports on zones of risk within our specialty. To approach this in a secure and appropriate manner, we considered forming a Patient Safety Organization. Designation of such an organization affords specific legal rights, but also places specific requirements on such an entity. Our intense research of this potential designation yielded great insight. Currently, it is not in the Academy’s best interest to pursue designation as a Patient Safety Organization. However, we do want to know what zones of risk exist for Academy members so they can ensure that the highest level of care is delivered to their patients. To this end, we can rely on articles published in peer-reviewed journals. However, it is difficult to have case reports on errors or sentinel events published in such journals. Furthermore, many ask if that is the appropriate forum for dissemination of such events. The study our group published in Laryngoscope in 2004 laid the foundation for many subsequent projects targeted at reducing harm and near-misses in our specialty. We hope that by collecting data we can address issues that affect our patients on a macro level that may not be identified in one-off reports or anecdotal vignettes. For example, if there is a device that has an issue at a frequency of 10-3, then that issue may never be evident to a single surgeon during a couple of decades. However, if 7,000 surgeons use the device, then infrequent issues could become rapidly apparent. The Food and Drug Administration has an excellent medication and device reporting system for adverse issues. However, when reviewing systemic defects with processes, some of these are not captured by such reporting mechanisms. An example of this would be the latent system defects in transitioning your office from a paper-based system to an electronic medical record process. This zone of risk (the potential for information technology to lead to adverse events) has only recently become evident in the patient safety and quality improvement world. However, a system that allows us to aggregate near-misses, adverse events, and errors would facilitate identification of this. The Patient Safety and Quality Improvement Committee is working diligently with Academy staff to create a web-based portal that members could access through the AAO-HNSF website. The portal would allow members to confidentially answer 10 brief questions on a near-miss, adverse event, or error. There would be no identifiable data, which is good and bad. The good we can all discern. The bad is that by having some potentially identifiable data, such as hospital characteristics, etc., we can learn more about the event and ways to minimize it. However, to ensure the confidentiality of the physician providing the report, it is absolutely imperative that only high-level information be obtained. We imagine you would submit a summary similar to this: “A 6-yo boy underwent a tonsillectomy and had a burn to the lip; I used xyz technique; I did the case, not a resident.” If we were to obtain a dozen similar reports, it would indicate that this is a potential zone of risk. We could then leverage our Academy resources to help prevent this condition. We are excited about the new web portal that will allow Academy members to input limited data about perceived or real safety issues; the end result would be an ability to see which issues affect Academy members and their patients and hopefully the most common sources of near misses, adverse events, and errors. We encourage members to write us with any topic of interest, and we will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.
Rahul K. Shah, MD, George Washington University School of Medicine, Children’s National Medical Center, Washington, DC
The Academy, via the Patient Safety and Quality Improvement Committee, is eager to provide membership with quasi real-time reports on zones of risk within our specialty. To approach this in a secure and appropriate manner, we considered forming a Patient Safety Organization. Designation of such an organization affords specific legal rights, but also places specific requirements on such an entity. Our intense research of this potential designation yielded great insight. Currently, it is not in the Academy’s best interest to pursue designation as a Patient Safety Organization.
However, we do want to know what zones of risk exist for Academy members so they can ensure that the highest level of care is delivered to their patients. To this end, we can rely on articles published in peer-reviewed journals. However, it is difficult to have case reports on errors or sentinel events published in such journals. Furthermore, many ask if that is the appropriate forum for dissemination of such events. The study our group published in Laryngoscope in 2004 laid the foundation for many subsequent projects targeted at reducing harm and near-misses in our specialty.
We hope that by collecting data we can address issues that affect our patients on a macro level that may not be identified in one-off reports or anecdotal vignettes. For example, if there is a device that has an issue at a frequency of 10-3, then that issue may never be evident to a single surgeon during a couple of decades. However, if 7,000 surgeons use the device, then infrequent issues could become rapidly apparent.
The Food and Drug Administration has an excellent medication and device reporting system for adverse issues. However, when reviewing systemic defects with processes, some of these are not captured by such reporting mechanisms. An example of this would be the latent system defects in transitioning your office from a paper-based system to an electronic medical record process. This zone of risk (the potential for information technology to lead to adverse events) has only recently become evident in the patient safety and quality improvement world. However, a system that allows us to aggregate near-misses, adverse events, and errors would facilitate identification of this.
The Patient Safety and Quality Improvement Committee is working diligently with Academy staff to create a web-based portal that members could access through the AAO-HNSF website. The portal would allow members to confidentially answer 10 brief questions on a near-miss, adverse event, or error. There would be no identifiable data, which is good and bad. The good we can all discern. The bad is that by having some potentially identifiable data, such as hospital characteristics, etc., we can learn more about the event and ways to minimize it. However, to ensure the confidentiality of the physician providing the report, it is absolutely imperative that only high-level information be obtained. We imagine you would submit a summary similar to this: “A 6-yo boy underwent a tonsillectomy and had a burn to the lip; I used xyz technique; I did the case, not a resident.” If we were to obtain a dozen similar reports, it would indicate that this is a potential zone of risk. We could then leverage our Academy resources to help prevent this condition.
We are excited about the new web portal that will allow Academy members to input limited data about perceived or real safety issues; the end result would be an ability to see which issues affect Academy members and their patients and hopefully the most common sources of near misses, adverse events, and errors.
We encourage members to write us with any topic of interest, and we will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.