Speaking Up: Improving Patient Care through Recognizing, Reporting, & Responding

Kenneth Levine, JD, PhD Kami Silk, PhD   

Co-Principal Investigators: Kenneth Levine, JD, PhD and
Kami Silk, PhD, Department of Communication, Michigan State University (MSU)

Co-Investigators:
Christine Jodoin, RN, Vice President, Nursing, Sparrow Health System
Anna Melville, MA, Michigan Health & Hospital Association, Keystone Center
Adam Novak, MA, Michigan Health & Hospital Association, Keystone Center
Ted Glynn, MD, Vice President, Medical Education, Sparrow Health System

This research aims to improve safe patient care and to help reduce hospital readmission by investigating how to best encourage Sparrow Hospital medical staff to speak-up when adverse events occur. To that end, the two aims are to: Aim 1: Conduct formative research via focus groups and survey methods to develop an understanding of the existing culture of speaking-up about medical errors and near misses. Aim 2: Develop an evidence-based intervention to increase and enhance Sparrow’s capacity to recognize, report and respond medical errors and near misses within system-defined time parameters.

Rationale/Significance. Speaking up in the healthcare setting is an important characteristic of patient safety, and is shown to have many influencing factors such as motivation, perceived support, and perceived efficacy of the behavior (Okuyama et al., 2014).  Through an understanding of (1) why medical errors and near misses are not always reported; (2) how to motivate residents and nurses to report adverse events by changing the organizational culture; and (3) aid in the creation of an innovative system that is easy and effective for the medical staff to report errors and omission, Sparrow should see both an increase in the reporting of errors and near misses as well as an increase in effective responses to these events.  Another important outcome would be the ability to track both the initial reporting of an incident and the feedback loop to management.  This should improve patient and caregiver safety, which corresponds with the CFIR mission. Despite technology interventions to facilitate anonymous reporting, the problem is endemic to hospital systems and can result in consequences for patients as well as colleagues (Attree, 2007).  There are two components to this inquiry, organizational culture and safe patient care.

Approach/Design/Setting/Sample/Methods/Outcomes.  To understand and create innovative ways to change the organizational culture to increase patient safety at Sparrow Hospital, our research team will facilitate a series of focus groups with two stakeholder groups: medical residents and ICU nurses. Analysis of the focus group data will inform the creation of an organizational survey to further assess the organizational culture as well as barriers and facilitators for speaking up. These efforts will aid in the development of an intervention to change the existing organizational culture and also to help inform the hospital administration on establishing best practices for reporting errors and omissions. 

Future Funding Opportunities.  PAR-15-303; Occupational Safety and Health Education and Research Centers (42) Department of Health and Human Services; CDC PA-15-147; AHRQ Small Research Grant Program (R03) Department of Health and Human Services; AHRQ PA-14-291; AHRQ Health Services Research Projects (R01) Department of Health and Human Services; AHRQ

Press Release here