Impact of the Innovative System-generated Adverse Events on Enhancing the Blame-Free Culture within JHAH

From the 2023 HVPA National Conference

Iyad Eid BSN, MSc HC, CPHRM, CPHQ, CPPS (Johns Hopkins Aramco Healthcare), Alber Paules MD, MBA, Ali Abandi MIS

This study was conducted at Johns Hopkins Aramco Healthcare (JHAH) in Dhahran, Saudi Arabia from the year 2019 to 2022. JHAH uses Datix as an electronic incident reporting system that requires all staff members to report all types of incident events including near misses. The reporting system is operated through a local web-based website from within the JHAH. Risk Management Division routinely reviews all Datix reports. Staring 2019, Risk Management division, in collaboration with the information Technology Department, established a linking mechanism between the Electronic Health Record (EHR) and the Incident Reporting System (IRS), in order to automatically generate (i.e., e-trigger) events into the IRS. This linkage aimed at increasing the adverse events reporting in order to ensure that those potential adverse events are not missed, in addition to their being addressed in a timely manner.

This study aims at identifying the impacts of this linkage on the system fixes initiatives and on the blame-free culture within JHAH.

A before-and-after study was implemented across all JHAH settings in order to identify the changes observed or noted post-implementation of the new approach of linking the Epic system (JHAH EHR) with the Datix system (JHAH IRS).

The 2022 data was compared to 2019 data and could show that there was an increase in the proportion of Datix events associated with “no harm” in 2022 (90%) compared to the ones reported in 2019 (79%). Furthermore, the comparison between JHAH’s Hospital Survey on Patient Safety Culture (HSOPS) results regarding the blame-free culture in 2018 versus in 2021 showed an improvement with a 16% increase in the responses supporting the need to report patient safety events, a 121% increase in the positive responses/actions towards errors, and a 21% increase in the responses supporting open communication about errors.

The study results suggest that linkage between the EHR and the IRS would help in enhancing the blame-free culture within the healthcare organization and would indirectly augment patient safety through minimizing events associated with harm.

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