Tracking near-misses part of proactive approach to risk management at Peterborough hospital
Monday May 12, 2008 -- Natalie Miller
Whether a back door is propped open or a medication mistake is averted, staff members at a Peterborough, Ontario hospital report potential hazards before they happen, the hospital's risk manager says.

“Traditionally in risk management, we fixed (errors) after the fact,” says Maureen Condon, co-ordinator of patient relations and risk management.

“We're trying to be more proactive.”

It's paying off. Last year of all error incidents reported, 20 per cent were possible risks, illustrating the incident reports are becoming more preventative.

“Everybody's involved,” Condon says. “We've got 2,000 eyes and ears.”

Peterborough Regional Health Centre has had a disclosure policy in place since 2003. Developed with reference to material from the Ontario College of Physicians and Surgeons and the Ontario College of Nurses, the policy was, in part, created in response to a number of potassium chloride deaths in Canada.

Disclosure policies aren't “new for us in theory or practice,” says Condon.“We've always been proactive about disclosure.”

Condon says as a risk manager she's pleased to see the The Canadian Patient Safety Institute's (CPSI) release on March 18 of the first-ever comprehensive set of national guidelines aimed at helping healthcare providers decide what to tell patients when it comes to errors or near-misses relating to their care.

The guidelines also outline how to develop a workplace culture free of speculation about blame, how to build a foundation for disclosure and how to implement the actual disclosure processes.

“We strongly support consistency across our organization,” says Condon. “But we're excited the guidelines speak more broadly. Healthcare is a big system.” Condon says having standards in place helps put healthcare providers on the same page.

“We're quite happy with the guidelines. It provides support for the direction we took in the past.”

She says the disclosure guidelines also reiterate to staff that the policies in place at Peterborough Regional Health Centre are supported elsewhere. The disclosure process at the Kawartha-area hospital involves frontline workers, managers and the risk management team.

Related story:
Being open with patients 'fosters trust' at Peterborough hospital

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