Interactive voice response system improves reporting of adverse events at hospital

Study in December 2021 issue of The Joint Commission Journal on Quality and Patient Safety

(OAKBROOK TERRACE, Illinois, November 23, 2021) – Incident reporting systems (IRSs) allow health care organizations to capture errors and identify near misses by engaging frontline personnel to report adverse incidents. However, studies suggest that voluntary reporting detects fewer than 10% of all adverse events.¹

New #jointcommissionjournal study: #IVRS improves reporting of adverse events at #hospital

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Improving the IRS process can facilitate more informative and timely data capture while providing greater opportunity to improve patient safety and quality of care. A new study in the December 2021 issue of The Joint Commission Journal on

Quality and Patient Safety, “Novel Telephone-Based Interactive Voice Response System for Incident Reporting,” identifies barriers to incident reporting and develops solutions to increase the ease and efficiency of the reporting process.

Diagnostic imaging staff at Niagara Health System–St. Catharines Site, St. Catharines, Ontario, were surveyed to identify barriers to incident reporting through the hospital’s existing web-based IRS. Barriers included lack of time, lack of feedback and complexity of the reporting system. Based on the barriers identified, two incident reporting methods were tested in successive phases:

A phone-based voice message mailbox to leave a 30-second maximum description of an incident.
A phone-based structured interactive voice response system (IVRS) with no time limit to describe an incident, dial pushes for binary information and a flow of instructions on which information to report.

Findings showed a significant difference in reports per day via the IVRS (3.43) compared to the existing web-based IRS (0.99). A significant decrease in the average time to make a report using the IVRS (97 seconds) compared to the IRS (644 seconds) was also identified. These findings support that IVRS may prove to be more efficient than web-based approaches and encourage higher reporting rates.

An accompanying editorial by Kaveh G. Shojania, MD, emphasizes the importance of recognizing the problem of excessive workload for nurses and other frontline staff as it relates to reporting incidents and conducting root cause analyses. “Scarce resources for patient safety research and operations may account for the lack of concrete progress over the past 20 years. That resource scarcity has only worsened with the tight fiscal constraints imposed by the ongoing pandemic along with the backlogs of care and widespread staffing shortages the pandemic has caused,” notes the editorial.

Also featured in the December issue:

Building a Program of Expanded Peer Support for the Entire Health Care Team: No One Left Behind (Froedtert and the Medical College of Wisconsin, Milwaukee)
Building Patient Trust in Hospitals: A Combination of Hospital-Related Factors and Health Care Clinician Behaviors (semi-structured telephone interviews with participants across the United States)
Disparities After Discharge: The Association of Limited English Proficiency and Postdischarge Patient-Reported Issues (University of California, San Francisco)
Changes in Safety and Teamwork Climate After Adding Structured Observations to Patient Safety WalkRounds (University Hospital, Basel, Switzerland)
Identifying Electronic Medication Administration Record (eMAR) Usability Issues from Patient Safety Event Reports (MedStar Health, Washington, D.C.)
A High-Value Care Initiative to Reduce the Use of Intravenous Magnesium Sulfate Through an Electronic Indication-Based Order Set (Parkland Hospital, Dallas)
Describing Evaluations of Decision Support Interventions in Electronic Health Records (commentary)

For more information, visit The Joint Commission Journal on Quality and Patient Safety website.

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Note for editors
The article is “Novel Telephone-Based Interactive Voice Response System for Incident Reporting” by Ben McNiven, BSc, BHSc; and Andrew D. Brown, MD, MBA. The article appears in The Joint Commission Journal on Quality and Patient Safety, volume 47, number 12 (December 2021), published by Elsevier.

The Joint Commission Journal on Quality and
Patient Safety
The Joint Commission Journal on Quality and Patient Safety (JQPS) is a peer-reviewed journal providing health care professionals with innovative thinking, strategies and practices in improving quality and safety in health care. JQPS is the official journal of The Joint Commission and Joint Commission Resources, Inc. Original case studies, program or project reports, reports of new methodologies or the new application of methodologies, research studies, and commentaries on issues and practices are all considered.

¹ Classen DC, et al. Development and evaluation of the Institute for Healthcare Improvement Global Trigger tool. J Patient Saf. 2008;4:169–177 .