During any hospital stay, at any hospital - civilian or military - incidents can occur involving a patient's safety and well-being.

To minimize these incidents, Madigan Army Medical Center and the Military Health System, or MHS, have partnered to develop a new patient safety reporting tool, using a commercial, off-the-shelf program used by the United Kingdom and Canada that Madigan piloted for the entire MHS.

"Madigan gets to try it, pilot it and tweak it so it works the best to work well for everyone else in the U.S. Army Medical Command," said Marion Christiansen, MAMC's patient safety manager.  "We are always in process improvement mode."

The basic premise of the program is simple.  Using the electronic system, staff and other Common Access Card holders can report safety issues and concerns online and anonymously.

"Anyone can report anything that they want," Christiansen said. "They can report safety concerns and issues or compliments."

Safety concerns may include anything from prescription or medication errors, patient falls, equipment problems and issues to dietary concerns. Specific types of things that people may report include: delays in getting meal trays, late medication, falls, wrong kind of meal delivered, and communication issues during patient transfers.   
The hardest thing to report is frustration, she said.

"Often a staff member is frustrated with things that do not work properly or just not as well as they should during their shift," she said. "These things often go unreported."

Madigan's Patient Safety Program is overseen by an interdisciplinary team consisting of providers, nurses, dieticians, lab workers, pharmacy staff, and many others who are involved with patient safety.

The reports are often read in real time and are typically responded to within a day unless the report comes in on a holiday or a weekend, Christiansen said.  Although the staff is encouraged to identify themselves when reporting an incident they are not required to do so.

"People have feared getting in trouble if they report a problem," she said. "There are no punitive repercussions for people who report an incident. We want them to identify themselves so we can follow up and let them know how the problem was taken care of."

Throughout the pilot of the program many benefits have been identified, Christiansen said.  With online reporting, staff members can identify more near misses sooner and help prevent serious injuries from occurring in the future, and they have standardized reporting of safety events in all military health facilities, she said. Also, the electronic system allows the patient safety staff to get better outcome data.

"This program allows us to query data and reports and graphics," Christiansen said. "It contains visual mechanisms that show where there are problems.  It also helps us to identify trends."

However, the primary goal is to make patients safer when they are in the hospital, she said.

"We want to continue to learn what the underlying challenges are to avoid causing harm to a patient," she said.

The pilot is expected to be released throughout the military in October.

While the new pilot utilizes staff computers, anyone - including patients - may call the Patient Safety Hotline at (253) 968-3322.