NR 544 Week 3 Reporting System Critique Example

Reporting System Critique: Following One Wrong-Patient Near Miss From the Box It Was Typed Into to the Manager Who Closed It, and Finding the Outcome Settled at the Category List Before Anyone Read the Facts

Student Name

College of Nursing, Chamberlain University

NR 544: Quality and Safety in Healthcare

Instructor Name

Month Day, Year

Reporting System Critique: Following One Wrong-Patient Near Miss From the Box It Was Typed Into to the Manager Who Closed It, and Finding the Outcome Settled at the Category List Before Anyone Read the Facts

The Route Chosen

This critique follows one kind of report on one kind of unit: a medication near miss involving two patients with the same surname, entered by a staff nurse on an adult medical floor of 30 beds at a community hospital. It traces the entry described in the Week 2 write-up from the moment it was typed to the moment it was closed, and asks at each stage what the system did with it. It does not review the reporting software as a product or the hospital's whole safety program. A critique that tries to cover everything produces observations nobody can check.

At each stage I mark whether I know how the stage works, from documents or direct observation, or believe it, from what colleagues told me. The distinction matters because much of what staff say about the reporting system is hearsay, and some of it is wrong.

Stage 1: The Form

Known. The form opens with the date and time of the event, the patient's record number and a category list of 14 event types, each with subtypes. The nurse chose "Medication" and then "Wrong patient." The form then asks whether the event reached the patient and assigns a harm level from a fixed scale. A free-text box follows, limited to 2,000 characters.

The category list is the first place an outcome is decided. It offers a finite set of things an event is allowed to be. The entry was accurate as a medication event, but its most important feature, two patients sharing a surname on one assignment, had no category and could only be written in the free-text box. Whatever the list omits is recorded as the nearest option and counted as that from then on. Pham et al. (2013) noted that many hospital reporting systems collect large numbers of reports with poorly structured information that is hard to analyze.

Stage 2: The First Reader

Known. Entries at the no-harm level are routed automatically to the manager of the unit where the event occurred. The patient safety office receives a weekly summary count but does not open individual no-harm entries.

Believed. Colleagues told me the manager reads the category and harm level first and opens the free text only when something in those fields looks unusual. I could not confirm this and would not assert it in a formal report. What is known is that the first reader is not a committee or an analyst but a single manager with many other duties, and that this manager is the only person who will ever read this entry in full.

Stage 3: Coding and Closure

Known. The manager has 30 days to review and close a no-harm entry. The closure screen offers a drop-down of dispositions, including "Reviewed with staff," "Education provided," "Referred" and "No action required," plus an optional comment. This entry was closed on day four as "Reviewed with staff," with the comment that barcode scanning worked as intended.

This is where two identical events part company. Had the same event been coded at a harm level that reached the patient, it would have gone to the patient safety office for review. The harm code, assigned by the reporter from a list, determined whether anyone beyond the unit would ever see it. Leape (2002) argued that reporting systems are useful only when reports receive expert analysis and produce a response; the routing rule means no-harm entries receive neither beyond the unit.

Stage 4: What Came Back

Known. When the entry was submitted, the system sent an automatic message: "Thank you. Your report has been received." No further message was sent to the reporter when the entry was closed. The reporter learned of the closure only by asking the manager two weeks later.

Believed. Several colleagues said they stopped entering near misses because "nothing ever comes back." Evans et al. (2006) found that lack of feedback was among the barriers staff most often gave for not reporting. The return path on this route ends at a receipt, and a receipt teaches the unit that typing an entry is an act of compliance, not a way to change anything.

The Finding

The route's outcome was settled early, at the category list and at the harm code, before anyone had weighed the facts in the free text. The category list had no place for a standing condition, so the condition went into prose. The harm code sent the prose to one reader, whose reasonable conclusion was that the safeguard worked. Nothing returned to the reporter. No stage was broken; each worked as designed. That is the critique: the design routes the most instructive kind of entry, a near miss exposing a condition, to the place least equipped to learn from it.

A working version of this route would produce something specific: a count of wrong-patient near misses on the unit, a note of which involved same-name pairings, and a short answer to each reporter saying what was done. None of those requires new software. They require a routing rule and a person with time to read.

It is worth being precise about what the critique does not claim. It does not claim the manager was careless; the closure note was accurate. It does not claim every near miss should go to the patient safety office, which would bury the office in entries it could not read. It claims that one kind of near miss, where a condition on the unit made the error possible, needs a different route from one where the error was simply a slip, and that the current design cannot tell the two apart because the form never asks. A single extra question, asking whether anything about the unit's conditions made the event more likely, would let the routing rule separate them. It would cost the reporter a few seconds and give the first reader a reason to open the free text.

Limits

This critique follows one entry. Other kinds of reports, such as falls or pressure injuries, may follow different routes and receive more attention. The believed stages rest on colleagues' accounts and should be tested by asking the manager and the patient safety office directly before any recommendation goes forward.

References

Evans, S. M., Berry, J. G., Smith, B. J., Esterman, A., Selim, P., O'Shaughnessy, J., & DeWit, M. (2006). Attitudes and barriers to incident reporting: A collaborative hospital study. Quality and Safety in Health Care, 15(1), 39-43. https://doi.org/10.1136/qshc.2004.012559

Leape, L. L. (2002). Reporting of adverse events. New England Journal of Medicine, 347(20), 1633-1638. https://doi.org/10.1056/NEJMNEJMhpr011493

Pham, J. C., Girard, T., & Pronovost, P. J. (2013). What to do with healthcare incident reporting systems. Journal of Public Health Research, 2(3), Article e27. https://doi.org/10.4081/jphr.2013.e27