Closing the Loop: Follow-up and Feedback in a Patient Safety Program

Authors: Gandhi, Tejal K.; Graydon-Baker, Erin; Neppl Huber, Camilla; Whittemore, Anthony D.; Gustafson, Michael

Source: Joint Commission Journal on Quality and Patient Safety, Volume 31, Number 11, November 2005 , pp. 614-621(8)

Publisher: Joint Commission Resources

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Abstract:

Background: As health care organizations establish patient safety agendas, attention has focused on creating less cumbersome systems for reporting errors. However, experience at Brigham and Women's Hospital (Boston) suggests that more emphasis needs to be placed on what happens after a report is submitted.

Follow-up and Feedback: Follow-up includes prioritizing opportunities and actions, assigning responsibility and accountability, and implementing the action plan. Feedback entails (1) follow-up to those who report issues and (2) communication to the hospital staff and clinicians about events and actions taken. Responsibility and accountability for improvements need to be assigned by senior administration to hospital leaders who can effect the needed changes. Hospital leaders, not just the members of the patient safety team, must own these changes or improvements. Events that require follow-up action are brought to the attention of risk management and the patient safety team through several mechanisms, including voluntary reporting of adverse events through a computerized safety reporting system, root cause analyses, and Patient Safety Leadership WalkRounds^™.

Discussion: Developing and maintaining a systematic method for feedback represents more of a challenge than the completion of any single recommended action item. However, it is the feedback to the reporter that perpetuates the influx of information and closes the loop. Developing the information-tracking database has made providing feedback easier and more reliable but significant effort is required to keep the database current.

Document Type: Research article

Publication date: 2005-11-01

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Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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Closing the Loop: Follow-up and Feedback in a Patient Safety Program

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