RL Solutions is Brigham and Women’s Faulkner Hospital’s safety reporting system. Below, the Patient Safety team answers frequently asked questions about the program. If you have additional questions about RL Solutions or would like training on how to report, contact Caitlin Parrott at extension 7679 or email@example.com or Chris Haffenreffer at extension 2450 or firstname.lastname@example.org.
Why should safety events be reported into RL Solutions?
A safety event helps identify vulnerabilities and safety gaps within systems that allow errors to occur that can impact patients. Safety reporting prompts corrective action to improve care and patient safety. RL Solutions reports also help trend patterns of problems, identify volume of impact and serve as documentation of incident follow up.
Why don’t people report?
There can be a perception that reporting will create a punitive response to errors that are reported. Some people worry that they will be “written up” based on errors or problems reported. However, in Just Culture, we analyze the hospital systems that surround and influence the event, as well as the choices people made during an event. This allows us to stay away from blame and focus our efforts on building a system that supports employees providing the safest and highest quality care. Sometimes reporting will help us clarify that a group of staff need more education on a particular issue or that we need to make changes to existing policies.
Why else don’t people report?
Some staff don’t report because they are unsure that reporting makes a difference. They may have worked in other places where reporting goes into a “black hole” and it feels like a waste of time to report issues as a result. BWFH has created a reporting system based on our culture of high reliability and continuous learning. We use reports to work on system problems and to improve patient care. Every report is read by leaders within the hospital at the local and administrative level. Our goal is to review and resolve issues within two weeks. Many of the improvements are highlighted in our weekly newsletter Last Week in Patient Safety. Additionally, staff can request written feedback within the reporting form, and staff are encouraged to ask their Director or the Patient Safety Department for an update on an issue they submit.
Who can write an RL Solutions report?
Any staff who witnesses an event that affects patients’ safety can submit that event. You do not have to be directly involved in the event to report. Some staff report for each other, particularly if one of the team needs to remain focused on the care of the patient. Events that affect staff safety should be reported as well. Staff can also report “near miss” or potential events, things that were caught before patients or family members were impacted but that could have been a problem if the staff had not noticed in time. Near miss reporting can help us make system changes to benefit patients and families without ever having an adverse event!
How long does it take to type a report into RL Solutions?
The electronic safety reporting system is designed to keep reporting brief by use of drop-down selection fields. We are able to run reports on how long it takes to enter an event and the time range can be as short as three minutes. The Patient Safety/Risk Management Department reviews every report and can fill in fields that may be left blank or can follow up to clarify additional information. For example, if you witness an event and do not know the name of the patient involved, we can investigate and complete those fields on the form.
How do I write a report?
The safety reporting system can be accessed from your Partners application menu. The icon is called “Safety Reporting BWH.” You then select the icon that best fits the event, fill in the fields with a green asterisk*, which are the mandatory fields, to the best of your knowledge and click “Submit.”
Who reviews the reports?
The Patient Safety/Risk Management Department reads all submitted reports daily. Directors are also automatically notified of all reports filed on their floor or unit. Depending on the type of event, other groups will assist in the review process. For example, for medication events, the Pharmacy Director and Managers provide additional reviews. Senior Leaders read most events weekly in summary reports so that they have awareness of the issues that are impacting patients, families and staff.
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