Purpose: The purpose of this presentation is to share an ambulatory care shared governance task force’s journey from its original purpose of reducing patient falls in ambulatory care areas in a large, multi-site ambulatory care system to educating staff about and promoting the use of the organization’s incident reporting system.

Description: Falls are identified as a nursing-sensitive indicator and safety event for the ambulatory care setting. Three service line-specific shared governance councils identified a need to systematically address patient falls in ambulatory care. The shared governance council created a patient falls-specific task force (n= 13 members) with representation from 4 clinics. Staff roles included unlicensed assistive personnel, registered nurses, quality, informatics, nursing director, and patient safety. Members noted that recall of patient falls and near misses within the past 6 months (n=7) did not match the number of falls recorded through the organization's safety incident reporting system (n=5). The falls reported did not match the patient identifiers for those recalled. The task force began a QI project using the PDSA cycle framework to address the incongruence between recalled falls and reported falls. The task force conducted an informal voluntary survey of front-line staff (n=71) regarding reporting system utilization. Survey responses noted 49% (n=35) of staff had never submitted an incident report. Several barriers to usage of the reporting system were cited, with not receiving information on incident reports occurring in the department (n=38; 54%), time to complete (n=29; 40.8%), and lack of knowledge of how to complete (n=25; 35%) as the top three barriers.

These findings represented a need to pivot the initiative to improving the collection and sharing of data on safety incidents to focus on a culture of safety that could drive future quality improvement work. The task force met with stakeholders from quality and department/nursing leadership to provide visibility to safety reporting numbers via dashboard reporting and engage them as key stakeholders in improved incident reporting.

Evaluation/outcome: The task force identified staff education initiative as a key intervention to improve knowledge and use of the incident reporting system among all ambulatory care clinic team members, which was like what Hamed and Konstantinidis (2022) found. The task force utilized quality and ambulatory care leadership partners to develop one-page educational guides on incident reporting for easy sharing via email and posted on visibility walls. Falls task force members also partnered with department leaders to regularly share data with front-line staff on submitted incident reports, including patient falls, and discuss and celebrate reported patient outcomes with the goal of enculturating incident reporting in the ambulatory care setting. Integration of the incident reporting system into the electronic health record also improved ease of use for staff. The implementation of the incident reporting training is currently in progress. Future goals for the task force include a 6-month re-survey of staff and review of incident reports to determine if the implementation improved reporting system utilization and if accurate reporting of patient falls warrants further quality improvement work.

Chrystal Lewis discloses that she serves as a presenter for Practicing Clinicians Exchange.

Tania Golo-Atkin BSN, RN

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