Best evidence statement (BESt) A formal follow-up process in the safety reporting system

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Applicability Issues

Tools for Implementation

• Create a process for feedback within the current safety reporting system.

Potential Facilitators and Barriers

• Time: staff not having enough time to write a report within the allotted time
• Knowledge: not knowing when a safety report needs to be written; for example, a report about "near misses or small issues"
• Fear of recrimination: staff not wanting to report/write incidents due to the possibility of "getting into trouble" with managers and other staff members

Potential Resource Implications

• Safety Reporting databases: to track and trend safety reports
• Personnel: to collect and report the data

Other Challenges to Implementing the Recommendation

• Confidentiality Issues: All safety reports are confidential. Suggest collaboration with the organization's legal department to allow these reports to be viewed by managers and then tracked and trended for appropriate follow-up.

Not stated

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Search Strategy

• Databases: PubMed: Medline, ERIC, Scopus, and Google Scholar
• Search Terms: Safety reports, incident report, standardized process, knowledge, process, risk management, closing loop, incident reporting hospitals, knowledge and process, feedback, evaluations, incident reporting and root analysis, incident reports and evaluation, health care reporting systems, incident reporting and feedback, standard process of incident reporting, evaluations
• Filters: English Language, any date filters: articles published after 2000
• Search Date: 8/30/12

Not stated

Table of Evidence Levels

†a = good quality study; b = lesser quality study

Not stated

Not stated

A formal cost analysis was not performed and published cost analyses were not reviewed.

This Best Evidence Statement has been reviewed against quality criteria by 2 independent reviewers from the Cincinnati Children's Hospital Medical Center (CCHMC) Evidence Collaboration.

Not applicable: The guideline was not adapted from another source.

Cincinnati Children's Hospital Medical Center

Not stated

Group/Team Members: Claudia McCarron BSN, RN, Specialty Resource Unit Days Team; Barbara Giambra MS, RN, CPNP Evidence-Based Practice Mentor, Center for Professional Excellence/Research and Evidence-Based Practice; Mary Shinkle MSN, Specialty Resource Unit RN Clinical Manager; Lori Puthoff, MSN, RN Clinical Director, Specialty Resource Unit Nursing

Conflict of interest declaration forms are filed with the Cincinnati Children's Hospital Medical Center Evidence-based Decision Making (CCHMC EBDM) group. No financial or intellectual conflicts of interest were found.

This is the current release of the guideline.

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

The following are available:

• Judging the strength of a recommendation. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2009 May 7. 1 p. Available from the Cincinnati Children's Hospital Medical Center Web site.
• Grading a body of evidence to answer a clinical question. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2009 May 7. 1 p. Available from the Cincinnati Children's Hospital Medical Center Web site.
• Table of evidence levels. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2009 May 7. 1 p. Available from the Cincinnati Children's Hospital Medical Center Web site.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

In addition, suggested process or outcome measures are available in the original guideline document.

None available

This NGC summary was completed by ECRI Institute on May 23, 2013.

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of this Cincinnati Children's Hospital Medical Center (CCHMC) Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

• Copies may be provided to anyone involved in the organization's process for developing and implementing evidence based care.
• Hyperlinks to the CCHMC website may be placed on the organization's website.
• The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents.
• Copies may be provided to patients and the clinicians who manage their care.

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.

Diseases and conditions requiring safety reporting

To evaluate, among nurses in the hospital setting, if the use of a formal follow-up process for safety reporting versus no follow-up process improves nurses' knowledge and awareness of the outcomes, resolution and best practices for the safety issues reported

All nurses in the hospital setting

Formal follow-up process for safety reporting

Nurses knowledge and awareness of the outcomes, resolution and best practices for the safety issues reported

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5b) are defined at the end of the "Major Recommendations" field.

It is strongly recommended that a formal follow-up process be used to improve nurses' knowledge and awareness of the outcomes, resolution and best practices for safety issues reported (Benn et al., 2009 [2a]; Wallace et al., 2009 [2a]; Gandhi et al., 2005 [5b]).

Note: This follow-up process could take the form of any one or more of the following: replying reliably to the reporter within a reasonable timeframe, replying immediately to the reporter, using the event to raise awareness through formal staff communication channels regarding the event and/or action taken (Benn et al., 2009 [2a]; Wallace et al., 2009 [2a]; Gandhi et al., 2005 [5b]).

Definitions:

Table of Evidence Levels

†a = good quality study; b = lesser quality study

Table of Recommendation Strength

Note: See the original guideline document for the dimensions used for judging the strength of the recommendation.

None provided