Description and Outcomes of the Doctorquality Incident Reporting System Used at Baylor Medical Center at Grapevine

Abstract

Problem

To improve error reporting so as to increase patient safety in a health care environment in which many barriers to reporting exist. Setting: Baylor Medical Center at Grapevine, a 104-bed hospital in Northeast Tarrant County that is part of the Baylor Health Care System.

Strategies for improvement

Partnering with DoctorQuality to provide a consolidated, Web-based form for error reporting, online education, and a risk analyzer, complemented by efforts toward cultural change including staff training, encouragement of feedback, and the use of financial and nonfinancial incentives to report errors.

Effects of change

After implementing the system, the number of events reported increased 250% to 500%; costs for data collection, analysis, and management decreased by $25,000 to $35,000 annually; and the time required to track errors and make improvements was reduced 25% to 50%. Further, managers and staff were very satisfied with the system, ranking it >4 on a 5-point scale.

Conclusion

The institution's partnership with DoctorQuality to create a single Web-based form for error reporting was successful in improving efficiency and ease of access in reporting. Further, the institution was successful in creating a new organizational culture around errors. The success was due in part to strong leadership, collaboration of multi-disciplinary staff, the ease of use of the system itself, and the effective educational, motivational, and communication mechanisms used.