Abstract
High-reliability organizations (HROs) are complex and have the potential for catastrophic failures yet operate with few such defects. Examples include; nuclear aircraft carriers, nuclear power plants, and air traffic control. Health care is also a highly complex industry with many catastrophic defects that would benefit from employing the principles of HROs. HRO reliability results from a capability to discover, manage, and reduce unexpected events. Paper-based reporting systems impede reporting of both actual and near-miss events. In April 2001, Trinity Health designed and implemented an anonymous Web-based reporting tool known as PEERs (Potential Error and Event Reporting System) that was based on the Aviation Safety Reporting System. The goal was to increase the reporting of actual events and near misses, facilitate the management of events, and identify potential safety problems before patients were harmed. Thirty-six Trinity Health hospitals and affiliates are currently using the PEERs system, and over 200,000 reports have been generated. Approximately 80 percent of these reports would have been overlooked in the paper system. The reports are standardized and are immediately available for use by the PEERs coordinator/safety officer. Significant care practice changes have resulted from PEERs reporting. In 2006, 59 root cause analyses were performed as a result of PEERs reports, 16 policies and 123 processes were changed, and an additional 50 policies are undergoing revision. A systemwide council of PEERs Coordinators meets regularly to share lessons learned and best practices related to patient safety. This information is routinely shared with management. The PEERs system nurtures a blame-free environment where reporting is encouraged. It has increased the reporting of events in a manner that allows for timely, efficient, and thorough analysis. PEERs facilitates the discovery, management, and eventual reduction of adverse events.
This resource is found in our Actionable Strategies for Health Organizations: Empowering Worker & Learner Voice (Psychological Safety).
