Adverse Event Safety Dashboard Closed the Feedback Loop for Frontline Clinicians

What was the reason for the change?

Most of the time, we talk about the importance of reporting adverse events so that quality and safety leaders can review the event, and decide follow-up actions and potential systems changes. Rarely, do we discuss ways to share the outcomes of reported adverse events back with the front-line clinicians or with the department as a whole. Many clinicians would mention to me that they would report adverse events but would never know the outcome of the event and so would feel that there was little impetus to continue reporting. This component of safety culture, “transparency”, was what we strove to target with this project.

What were we trying to accomplish?

Sharing outcomes and results of reported adverse events back with front-line clinicians, improving transparency. We also were hoping to improve safety culture as a whole, and potentially increase the likelihood that clinicians would report adverse events. Dashboard as a concept exist but are usually geared towards medical floors/units to identify at-risk patients. We took the same idea but used a dashboard to summarize reported events and the quality/safety leader’s actions on those reports, including planned/accomplished systems changes.

How will we know that a change is an improvement?

I conducted a pre- and post-intervention survey after the pilot to assess satisfaction with the dashboard, knowledge of outcomes of reported adverse events, perception of safety culture, and likelihood to report future adverse events. Amazingly, most providers reported not just better understanding of reported events + their outcomes, but also improved safety culture, transparency and felt they would be more likely to report future events!