(62 - Saturday) Team-based multidisciplinary review of safety event reports mitigates the efficiency thoroughness tradeoff for learning and improvement within complex ICU environments

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Abstract: INTRODUCTION
Safety event reporting systems intend to prevent future harm and mitigate risk. To accomplish this, prompt learning, multidisciplinary alignment, prioritization of workload, and action-oriented intervention are essential. In our complex heart center, we observed gaps in “work-as-done” vs “work-as-imagined,” ineffective information sharing and lack of loop closure for reported safety concerns. We implemented a team-based process to accomplish timely confidential multidisciplinary review, alignment of interpretation, and unified action on safety reports within multiple ICUs in our system.

METHODS
Safety events were captured in our commercial electronic reporting system. Authorized reviewers [Safety Event Review (SER) team] accessed reports imported into a generally available software’s locked channels that served as a single source document. The SER team performed comprehensive reviews and thematic categorization. The reports were labeled after review as CLOSE: completed actions, TRACK: actions underway and OPEN: action-plan needed. After successful sustenance of this process for Cardiac ICU (CICU), the process was extended to Adult Congenital Heart Disease Unit (ACHDU). For the OPEN reports, we performed Failure Mode Effects Analysis (FMEA) to prioritize and deploy actions. The efficiency metrics (review completion within one month of filing and OPEN events reduction) were temporally compared using Chi Square or Fischer’s Exact Test, *p < 0.05 and the actions completed are descriptively summarized.

RESULTS
The SER team reviewed 868 of 988 filed reports for CICU over 14 months, 190 of 192 filed reports for ACHDU over eight months and categorized them into six themes. The completed reviews for CICU increased from 422/541 (78%) to 445/446 (99%) [p < 0.001] and OPEN reports decreased from 161/422 (38%) to 22/446 (5%) [p < 0.001]. For ACHDU, the completed reviews were 66/68 (97%) and OPEN reports 4/66 (6%) in the initial half and these reached 100% and 2/224 (1.6%) respectively in the later period. We accomplished regular maintenance of FMEA dashboard and information sharing of themes and actions. Individual leaders committed towards deploying and completing actions within their disciplines and multidisciplinary actions were launched efficiently given that stakeholders were already engaged. Organizational level actions were owned by quality leaders who facilitated integration with existing workgroups or creation of new workgroups to implement solutions. Some examples of interventions included: correct matching of units for narcotic infusions and bolus doses on infusion pumps, creating critical laboratory values to trigger alerts for PTT Hepzyme and processes to decrease breast milk wastage.

CONCLUSIONS
We accomplished sustainable, prompt multidisciplinary review of safety reports and action implementation in busy ICUs within our heart center. This model is replicable to other areas of the organization, fosters collaboration, and creates efficiency of quality and safety work