189 - Speaking up for Safety: Identifying Barriers to Patient Safety Event Reporting Through Student-Led Hospital Rounding

Publication Number: 3181.189

Jeanna Auriemma, Wake Forest Baptist Health - Brenner Children's Hospital, Winston-Salem, NC, United States; Kathryn K. Ragland, Cornell University, Asheville, NC, United States; Linda Esposito, Advocate Health, Winston-Salem, NC, United States

Background: Voluntary patient safety event (PSE) reporting is a cornerstone of high-reliability healthcare and provides insight into system vulnerabilities to prevent harm. However, voluntary reporting consistently lag automated detection mechanisms.
To improve safety event reporting in one pediatric acute care unit, leader safety rounds were implemented to promote reporting culture and improve confidence that reporting will lead to improvement in processes. Leaders also introduced education on safety culture and how to report, without an improvement in reporting counts over 1.5 years. This raised concern that leaders did not understand the specific barriers to reporting on their unit despite their presence and engagement.

Objective: Staff may be reluctant to disclose reporting barriers directly to leaders as it may undermine perceptions of professional competence. To mitigate hierarchical challenges, an undergraduate intern conducted a diagnostic assessment of PSE reporting with frontline staff through a semi-structured interview at nursing stations (July 2025).

Design/Methods: Interview questions included whether the staff noted a safety event and near miss event on their most recent shift, and their main barrier to reporting. Two follow-up questions assessed whether any events noted were entered into the hospital PSE reporting system. Anonymous interview responses were then analyzed and used to inform a key driver diagram to select change ideas for a unit-based QI project.

Results: 70 staff members were interviewed. 22 observed a safety event; 12 observed a near miss on their most recent shift. 19 of 22 (86%) did not report the safety event, 6/12 (50%) did not report the near miss. Time constraints was the most frequently cited barrier (44%) (Fig 1).
Based on time being the most common barrier, a pilot QI project (start date: July 27, 2025) was implemented which instituted a "safety pause" about 1 hour before the end of shift led by the unit charge to identify any safety events from the current shift. This included a request to enter PSE reports in real time.
Reports unable to be entered were incorporated into shift handoff huddles, and the oncoming shift leader was responsible for entering the PSE report.
PSE reporting counts were tracked monthly (Fig 2).

Conclusion(s): Leaders were previously not focusing on the biggest barrier to reporting in their area. Identifying time as the most common barrier influenced the first key intervention for a PDSA cycle which has resulted in a doubling of the monthly PSE reporting count within 1 month and tripling within 3 months.

Figure 2. Safety Event Reporting Counts
Reporting counts did not improve despite multiple interventions from January 2023 through June 2025 with a mean of 29 per month. After student led rounding informed the top barrier and a initiative directly addressed this barrier, monthly reporting has consistently increased.

Figure 1. Top Barriers to Safety Event Reporting
Although leaders believed culture and education were the top barriers to reporting, staff disclosed to the student that time was the biggest barrier.