Background Safety event communication is imperative to reduce repeat events within a hospital. We realized that when an event occurred, follow-up and action items were implemented at the local level but there was not a way to quickly alert other areas within the hospital who may be at risk for a similar event. Methods A standardized method was developed to communicate and prevent similar events. An algorithm was developed to help define what events are communicated and how another area can assess the risk within their local area and intervene as needed. When all areas were notified via a communication alert that a safety event happened in a local area, the patient safety leaders systematically assessed the risk of a similar event in their area. The leaders then replied to the communication alert system indicating that they had performed the risk assessment. Results In the first 19 months, 65 safety event alerts were sent. Members from the team responded a total of 959 times with their next steps after learning about a safety event. Of the 959 comments, 48 of the comments were conversational, 403 of the comments stated there was not risk of a similar event in their area, and 508 indicated that there was risk of a similar event happening in their local area and that action was taken to mitigate that risk. This resulted in 508 times when the safety leaders in other areas throughout the hospital developed local plans to prevent a repeat event. Conclusion Reducing safety events in the hospital setting is a complex process. Communication of known events could potentially reduce de ja vu events. The risk assessment process is one way to spread communication and response to safety events as they occur.
Figueroa-Altmann et al. (Fri,) studied this question.