Close Call Reporting System
From: M. D. Anderson Department of Performance Improvement
Date: January 15, 2008

Krisanne Graves: Hi, I am Krisanne Graves, with the Institute for Healthcare Excellence in the Performance Improvement Department at M. D. Anderson.

We are here today to talk about reporting incidents and close calls and why we need to do it. When we talk about safety in healthcare, we talk about the absence of preventable harm. The goal has always been and always will be to do no harm. We do recognize however that healthcare workers are human and when humans are involved in the system, errors are inevitable. They are just going to happen. We can learn from our experience and we can't learn what we don't know about.

Dr. Lucian Leape is a pediatric surgeon and pioneer in patient safety research in the United States. He says that human beings make mistakes because the systems, the tasks and the processes they work in are poorly designed. It is our belief that very few if any healthcare providers, ever come to work with the intent or goal of causing harm. We all come to work to do the best that we can.

A lot of the ways that we do our work is through processes that have existed for years or even decades. They've been changed over time with the intent to make healthcare safer, and easier to provide.

However, sometimes those changes lead to unintended results. The issues may be hidden for a long time or very interestingly they may be right out in the open and we just get used to working around them. Perceiving that is easier to avoid something than it is to overhaul an entire system or process.

Now when I say system, what exactly do I mean? A system is a combination of parts that interact and function as a whole. Each part of the system is required for that system to function and each part of the system usually can also be viewed as a system itself. Some examples of systems are an automobile, a human body, the respiratory system and even a hospital.

So why can't you do things like these? Start a car and drive, open a washing machine and have the spin cycle continue? Open a filing drawer when one is already open, or even store concentrated electrolytes in a patient care area? If we look at these things from a system's perspective, the answer is really pretty ingenious. Someone recognized the trend in the accidents or in close calls around this issue and knowing that part of the human condition is that we're not perfect. That all people will do things unintentionally that may cause harm or danger. What happens if we blame the individual who just happened to be in the wrong place at the wrong time? Well how does that individual perspective work? The individual perspective is a normal characteristic of being human too, but it also leads to hiding, to covering up, and to denial. Generally very little gets fixed. And people generally become reluctant to report.

If we take a different perspective, that of a systemic view, we may recognize problems in design, training, maintenance, or policy that can lead to or allow human failure. These defects can lie dormant for long periods of time and it may take just the right combination of conditions and a simple human error that trigger an accident. In this view, issues are more likely to be identified to be talked about, and be acknowledged. This is when we believe that things get fixed.

One way that M. D. Anderson has tried to ease the learning in performance improvement process is through reporting. There is now a single, portal, institution wide electronic reporting method for incidents and close calls. Anywhere on the intranet site that you see the words Safety Reports or Incident Reporting Tool, or the icon that you see on the screen, you have found that route. Once you select the safety report's icon, you have three options. Are you reporting an incident? If so, select Yes, the event did reach the patient or visitor. Are you reporting a close call then select no. The event did not reach the patient or close call. And the definition of a close call is a potential error that could cause harm if it did reach the patient. It does not however reach the patient and it therefore does not cause harm. It can be caught through intention or just by luck.

Now if you want to report more specifics there's something else you can do. Important to note is that if an event does reach the patient, its important to use the incident reporting system so you need to say yes, that the event did reach the patient or visitor. And if you've never reported an incident there's a tutorial for you to look at. If you do want to report a close call and you do want to report in anonymously, use UTCCRS, by selecting No, and then confirming that you do want to report an incident anonymously. Once you get to UTCCRS, click Enter a Close Call, and then all the fields are optional. Its really that simple. The system asks questions about you and the close call that you are reporting. Anyone employed at M. D. Anderson can report a close call. That includes direct patient care providers, like nurses and doctors, and anyone else. Housekeeping, administrators, anyone. We want to know what you see. And it only does take about two minutes. When you reach the contributing factor screen, think about what occurred in the path of this close call. How did it get through to you? What holes were in the Swiss cheese if you look at with a systems model? What pieces came together to allow this event to happen? So yes, the goal really is to increase reporting. We want to increase close calls and incident reports. And no, more reports won't make us look bad. Increasing reports over time demonstrates that we're focusing on safety, rather than on blame. So why do we continue to need this program? We want more reports so that we can have more data. We want more data so that we can have more to learn from. And hopefully have more action. And that action, in fact, we hope leads to safer work environments for you and safer patient care. So, if somebody tells you that they've seen an incident or a close call, report. Just do it.

Thank you.