Anonymous vs. Confidential Notification

Anonymous vs. Confidential;Notification

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Anonymous vs. Confidential; Notification

Anonymous - completely unidentifiable

Confidential - identifiable but held in confidence

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Anonymous Notification

• No further gathering of information

• Unable to identify root causes

• Takes reporter out of the process

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Anonymous Notification

• Deficient safety culture in the organization

• Fear of punitive action

• Sense of action will not be taken to correct problem

• Lack of training and education on safety culture

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Confidential Notification

Wikipedia, the free encyclopedia

• Problems reported In confidence

• Allows events to be reported without fear of blame

• Allows analysis of the reported incidents

• Can spur the development of measures to make the system safer

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Confidential Notification

• Allows for follow up interviews

• Allows you to probe for secondary information

• Allows reporting without fear of disclosure

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Confidential Notification

In Summary Confidential Notification

• Facilitates the disclosure of human errors

• Reduces fear of retribution or embarrassment

• Enables others to learn from previous mistake

J Am Med Inform Assoc. 2003 Nov‐Dec; 10(6): 531–540ICAO DOC 9859‐Safety Management Manual

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Reporting Systems

Combination of both Anonymous & Confidential

=+

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A Complete Safety Culture

InstitutionalReporting system

Confidential

RO_ILSNational Reporting 

SystemConfidential

Radiation Oncology

Reporting systemNon‐Anonymous but confidential 

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What to Report

• Any unsafe condition – variance/near miss

• Anything that leads to confusion about how to care for a patient

• Any software/hardware problems

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Whom to report to

• Inter dept. system

• Hospital System

• RO-ILS

• State

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Non-Anonymous, but Confidential

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Confidential Information Reported Out

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Confidential Information Reported Out

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2004 Hospital Implemented the RiskPro Reporting System

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Formation of the Radiation Oncology -Incident Learning System (RO-ILS)

• Designed to address the expressed needs by the Radiation Oncology community

• Voluntary participation• Offered currently at no cost to the participants• Beta Tested Jan – June 2014• Went live nationally June 19, 2014

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RO-ILS Workflow and Relational Process

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Provider Reports Incident

Analysis of 

incident

Decision to report to PSO

Provider’s PSES and local activities

Analysis, reports, variety of safety 

activities

ASTRO

Clarity PSO PSES

Radiation Oncology Community

Learning reported back to provider

AAPM

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If not Anonymous-State Report

Date:Report on Medical Event of Date:

Registrant:Facility:

Facility Registration No.:

Machine Registration No.:Dates of Medical Event:

Date of Discovery:

Prescribing Physician:Machine:Treatment modality:Prescription dose:Intended treatment site:BRIEF DESCRIPTIONEffect of Event / Dose AnalysisRoot Causes AnalysisPlanned or Taken Corrective Actions

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Anonymous vs. Confidential; Notification

Key Notification Principles-From Skybrary

• Trust - The reporters must be certain that the information will not be used against them.

• Non-punitive - Reporting person must be protected against legal, administrative or disciplinary sanctions, except in case of gross negligence, criminal activity or intent.

http://www.skybrary.aero/index.php/Voluntary_Occurrence_Reporting

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Key Notification Principles-From Skybrary

• Inclusive Reporting Base - The systematic approach to safety management required that voluntary reporting be targeted at all aspects of the department.

• Confidentiality - Non-punitive systems are based on confidential reporting.

• Independence - Ideally, the voluntary reporting system will be operated by an organization that is separated from the State regulatory authorities. This organization will collect and analyze safety reports and feed the results back to the regulatory authorities and the aviation community.

http://www.skybrary.aero/index.php/Voluntary_Occurrence_Reporting

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Key Notification Principles-From Skybrary;

• Ease of reporting - Submitting a report should be as easy as possible for the reporter.

• Acknowledgment - Whenever possible, feedback on the actions taken in response to a report shall be provided to the reporting person.

• Promotion - The de-identified information received from the voluntary reporting system should be made available to the radiation community in a timely manner.

http://www.skybrary.aero/index.php/Voluntary_Occurrence_Reporting

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Who is Reporting Events?Where are they being caught?

05

101520253035404550

7/1/13‐12/31/13

1/1/2014‐6/17/2014

Confidential Notification

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How To Communicate Feedback

•QA meetings•Conferences•Reporting systems

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In Summary

We need to build better Confidential Safety Organizations

Through…

• Communication• Leadership• Training • Reporting systems

...

20%

20%

20%

20%

20%1. Allows for follow up interviews. 2. Identification of all root causes.3. Reduced Fear of punitive action.4. Allows reporter to be part of the

countermeasure process.

10

Which is an ingredient for an Anonymous Notification?

...

3. Reduced Fear of punitive action.

10

Which is an ingredient for an Anonymous Notification?

References:

"ASRS: The Case for Confidential Incident Reporting Systems. NASA ASRS Pub. 60". NASA. Retrieved 2014-05-15.

"ASRS - Aviation Safety Reporting System: International". NASA. Retrieved 19 May 2014.

Which of the following is an ingredient for Confidential Notification?

20%

20%

20%

20%

20% 1. Reduced opportunity for reporter to be part of the system

2. No probe for secondary information3. Impedes development of measures to

make the system safer4. Increases possibility of error being

reported

10

...

4. Increases possibility of error being reported

10

Which of the following is an ingredient for Confidential Notification?

References:

"ASRS: The Case for Confidential Incident Reporting Systems. NASA ASRS Pub. 60". NASA. Retrieved 2014-05-15.

"ASRS - Aviation Safety Reporting System: International". NASA. Retrieved 19 May 2014.

Which of the following is one of the key notification principles from Skybrary?:

20%

20%

20%

20%

20% 1. Individuals should not feel obligated to fill out a report2. Feedback shall be provided by reporting individual3. Punitive systems are based on confidential reporting4. Voluntary reporting systems will be operated by State regulatory authorities.

10

One of the key notification principles from Skybrary is:

2. Feedback shall be provided by reporting individual

10

References:

http://www.skybrary.aero/index.php/Voluntary_Occurrence_Reporting