Incident Tracker: An Intranet‐Based Decision Support Tool for Analyzing, Aggregating, and Reporting Sentinel Events

Background:

Hospitals are required to review sentinel events (SEs) and develop root cause analyses (RCA), implement action plans, and monitor the effectiveness of implemented plans. Vague definitions of safety terms and nonstandardized review processes impede these efforts. The World Health Organization (WHO) and the Joint Commission (JC) developed an International Classification for Patient Safety (ICPS) that categorizes safety incidents with standardized terms and conceptual domains. Although ICPS may have promise to improve SE reviews, integration of the ICPS model into a decision support tool and database for aggregate reporting of safety incidents has not been reported.

Purpose:

We developed an intranet‐based decision support tool and searchable reporting system called Incident Tracker (I‐Tracker) designed around the ICPS framework.

Description:

FileMaker Server 11 Advanced software hosts I‐Tracker on a secure server accessible by Web browsers or client software at medical center workstations. I‐Tracker guides SE RCA groups through reviews with structured questions and tools for developing timelines, hazard assessments, fishbone diagrams, action plans, and standardized reports aligned with the ICPS framework. Drop‐down lists, help windows, windows with live access to iIternet educational resources (e.g., AHRQ, VA safety sites), default entries, and audio prompts are provided. Patient outcomes are graded with severity scores in physical, psychological, social, and economic domains. I‐Tracker also generates summary reports of multiple incidents and finds similar events within a database engine as defined by searches of key words. The database also stores documents used in an RCA or generated by action plans (e.g., new policies) for review by quality staff or future RCA groups as they begin their work. Individual action‐plan items have a background project management resource that allows quality leadership to monitor progress at the action plan development and implementation stages. I‐Tracker is fully functional, with 15 SEs entered into its database. Senior physician and quality staff leadership have reviewed the generated reports compared with previous nonstandardized reports and supported the wider application of I‐Tracker across a 4‐hospital regional system. Nursing and quality staff have endorsed the system and are now undergoing training.

Conclusions:

The WHO–JC ICPS framework is adaptable for integration into an intranet‐based decision support tool and database that standardize the RCA process and streamline the generation of individual and aggregate reports of patient safety incidents. I‐Tracker provides improvements in efficiencies of group processes, comprehensiveness of RCA, and standardization of reports that has received leadership endorsement for system‐wide implementation.

Disclosures:

S. Marsal ‐ none; J. Heffner ‐ none