The Science Journal of the American Association for Respiratory Care

2011 OPEN FORUM Abstracts


Peter J. Black, James Y. Findlay, Steve E. Sittig; Respiratory Care, Mayo Clinic, Rochester, MN

Background: A culture of safety is essential to the success of all hospitals. Event reporting (near-misses, sentinel events) is an important part of this process. At our institution respiratory therapists (RT) are encouraged to report events by calling an event pager. As part of a Respiratory Care Department safety initiative we interviewed staff therapist through casual conversation about reporting events and discovered that staff did not report all events. This was attributed to miscommunication with nursing, concerns regarding fear of retribution and ambiguity of near-miss and sentinel events. We hypothesized that provision of appropriate education to RTs would improve understanding of the event reporting process and encourage event reporting. The department adopted a plan to provide event reporting education to our respiratory therapists as an excellent way to promote safety. Method: A poster presentation with discussion was developed. This covered: a culture of safety, non-punitive environment, what events are, differences between near-miss versus sentinel, why do we report and how to report. All RTs attended the presentation in early January, 2010. A retrospective review of three years of event data was done one year after the poster presentation. The total number of events for each year was tabulated and then pre- and post-education years compared as a percent increase or decrease in reported events. Data were analyzed in Excel spread sheet. Results: Total events reported by RTs in 2008, 2009, 2010 were 28, 29, and 42, respectively (Table 1.). A review of three years of data displayed an increase in event reporting of 50% (2008), 44.8% (2009) when compared to 2010. Conclusions: Providing appropriate education improved RTs understanding of the event reporting process. Our department observed an increase in event reporting one year following the poster presentation. This will presumably translate into appropriate event reporting and an enhancement of the culture of safety in our institution. Respiratory Care departments should include a directed educational component as part of an event reporting process. Sponsored Research - None Table 1. Comparison of Event Reporting Pre- and Post-Education