RL DATIX is a reporting tool that UTMB uses to input, track, analyze and report patient safety and incidents data. Use of this tool supports UTMB’s Culture of Safety, and all staff are encouraged to use the reporting system.
The use of this tool supports UTMB’s goal of functioning as a High Reliability Organization. An example of an RL DATIX event reporting experience and how impactful reporting can be to our organization was shared by Stefanie Weiman BSN, RN, CCRN-K, Clinical Educator, CLC Pediatrics:
“I fell in love with nursing because you can do a task in a myriad of ways and still get the same result. As I entered into the role of a preceptor and also a charge nurse, I was able to observe and appreciate that everyone thinks just a little differently than the next person. I also started seeing different mindsets bring to light how different processes and systems have shortcomings and challenges. Finding and fixing those issues is one of the coolest parts of my job. It doesn't matter how big the change is. It all gets me jazzed to come to work each day!
“In a previous job, I was assigned to read, investigate and respond to the RL Datix reports pertaining to our unit. You wouldn't believe how many issues were fixed or processes were changed because one person decided to report it. We believed: You are reporting an event, not a person.
“The first RL Datix I ever placed regarded a mistake I made. But we found out there were multiple issues: There wasn't a good way to place the particular order. The one order contained multiple orders within it. The previous RN that acknowledged the order didn't understand it. I took the RN’s word for it and didn't review the order myself.
“In one patient event, four different processes and/or systems were looked at. The hospital changed an order set to ensure those types of patient events could be avoided in the future. That's when I saw the power of reporting.
“So many different eyes saw my 'mistake' at a different level. I was never asked, 'How could you do this?’ “Instead, multiple entities were asked, ‘How could this happen?' because they were charged with finding a way to make sure it didn't happen to another patient and to make sure other RNs and physicians weren't put in that situation again.
“Not too long ago we had an event on our unit. We had a toddler in need of a PICC for long-term antibiotics. We are a relatively new pediatric unit functioning within a hospital that services mostly adults. There are a handful of services that are difficult to come by for our smaller patients. We were lucky that the IR physicians were willing to attempt a PICC placement on a patient that is uncommon for them.
“We are also fortunate for a community hospital to have interventionalists and anesthesiologists that coordinate their time and efforts for our pediatric patient procedures. The PICC placement was a success and the patient returned to the unit after being recovered in the PACU.
“The nursing and hospitalist team noticed that multiple attempts were made on the patient in order to obtain the PICC line. It appeared that the number of attempts went beyond what is commonly practiced, so an RL Datix was submitted. It's important to remember that the event is reported, not a person! I have no idea what happened in IR or who was in the room when the PICC was placed. I was only reporting a situation I witnessed.
“From that RL Datix, a conversation started. It started because the right leaders were involved. They looked at the situation and all of the systems and processes that affected the patient. The leaders pushed for best-care practices and supported one another. Now, we have our Vascular Access Team trained in Pediatric PICC placement! Because I reported an event using the RL Datix, UTMB supports a new patient service.”
If you have a story of how RL DATIX reporting made a difference to you and your daily work, please let us know so that we can share your experience.