The randomized, controlled trial funded by the grant focuses on a pilot study program, developed at Cedars-Sinai, called the Safety Action Feedback and Engagement (SAFE) Loop. The trial will compare this program's effectiveness in boosting reporting rates and lowering safety lapses against standard protocols.
"The SAFE Loop is designed to overcome several limitations of existing hospital incident reporting systems," said Teryl Nuckols, MD, director of the Division of General Internal Medicine in the Cedars-Sinai Department of Medicine. "It includes improvements to the process itself and also two major innovations that help close communication gaps." Nuckols is the principal investigator for the AHRQ grant.
Lack of effective feedback is a significant weakness in current reporting systems, she said. Such systems typically focus on educating nurses, physicians and other staff about reporting incidents and enhancing a non-punitive culture, for example. The SAFE Loop goes further by providing standardized procedures for investigating high-priority events and, importantly, critical feedback to nurses about the results of investigations and mitigation plans, Nuckols explained.
"In particular, the SAFE Loop is intended to improve nurses' perceptions of incident reporting, which is essential given that nurses are key guardians of patient safety and generally submit most of the incident reports in the hospital,” explained Bernice Coleman, RN, PhD, ACNP, FAAN, assistant professor of Biomedical Sciences and director of Nursing Research at Cedars-Sinai. She is a co-investigator for the grant.