Author(s): Dawn Evans, DNP, MSN, MBA, RN, PHN, CPPS, CPHQ
Director of Patient Safety, Quality, Infection, & Pop Health
Barton Health

Dr. Evans serves as the Director of Patient Safety, Quality, Infection, and Population Health Nursing for Barton Health in South Lake Tahoe, California. Dr. Evans has worked in Patient Safety and Quality since 2010.Dr. Evans holds a Doctor of Nursing Practice degree from the University of Phoenix where her focus was on patient harm and event reporting; a Master of Science in Nursing from the University of Nevada, Las Vegas; a Master of Business Administration in Healthcare Management from Western Governors University; and a Bachelor of Science in Nursing from Sonoma State University. She is a Certified Professional in Patient Safety (CPPS), Certified Professional in Healthcare Quality (CPHQ), and a TeamSTEPPS Master Trainer. Dr. Evans has been a member of the National Association for Healthcare Quality since 2019. Dr. Evans is passionate about ensuring all patients receive safe, high-quality care.

Competency Domain: Patient Safety

Description: Medical errors and harm are global phenomena and a top ten leading cause of death, accounting for over 251,000 annual U.S. deaths. The Salzburg Global Seminar statement (2019) emphasizes the analysis of real-time incident data to identify harm. Incident underreporting impacts patient safety and inhibits organizational response. Nurses are the primary reporters of events. Studies identified nurse barriers to reporting incidents, including system usability, defined as electronic system end-user friendliness. This session will provide an innovative approach to integrating nurse input when redesigning or implementing an event reporting system that can improve the usability and quantity of submissions. Problem: Medical errors are a global phenomenon and a top ten leading cause of death (WHO, 2020). Nurses underreport incidents due to system complexity and poor usability. To address this problem, a quality improvement project was performed incorporating nurse input to improve usability and increase the rate of incident reporting. Measurement: John Brookes (2013) System Usability Scale (SUS) was utilized to collect usability data. A valid and reliable tool, SUS is an industry-standard in software usability assessments. In addition, data was collected on rates of event report submissions for hospital clinical care departments before and after the intervention. Analysis: Nurse demographics were computed using descriptive statistics. Quantitative testing utilizing the Mann-Whitney U test and System Usability Scale (SUS) scoring were performed to measure results. Implementation: Nurse collaborative redesign sessions focused on event reporting template redesign to improve usability. Disagreement among nurses and key stakeholders required inter-professional collaboration to move event reporting template changes forward. Nurse participation brings value to revising incident reporting systems that enhance usability. Results/Discussion The redesigned systems SUS scores exhibited improved usability. Mann-Whitney U testing demonstrated the redesigned systems SUS score (Mdn = 78.75) exhibited a statistically significant difference from the existing system (Mdn = 51.46, p = .003). Nurse collaboration and PDSA were critical. The organization uses one incident reporting system assuring sustainment.

Evaluation: Complete Poster Evaluation