Whoops!
Frequently Asked Questions
Click HERE to submit a report of a near miss into the Whoops! system
Overview of Whoops! System
- What is Whoops!?
Whoops! is an online anonymous near miss (close call) reporting system for reporting close calls committed or observed in the Texas A&M Clinical Learning Resource Center or other Texas A&M Health Science Center (TAMHSC) simulations (e.g., Disaster Day). It was developed for educational and research purposes to be used by TAMHSC students, faculty, staff, and standardized patients during medical simulations. It is also used to report errors that occurred in case studies read or viewed as a part of course curricula.
The structure of the system was inspired by the University of Texas Close Call Reporting system which is described in the following articles:
Martin, S. K., Etchegarary, J. M., Simmons, D., Belt, W. T., & Clark, K. (2005). Development of The University of Texas Close Call Reporting System. Advances in patient safety: From research to implementation. Vol. 2: Concepts and methodology: AHRQ Pub. 05-0021-2. Rockville, MD: Agency for Healthcare Research and Quality. https://www.ahrq.gov/downloads/pub/advances/vol2/Martin.pdf. Accessed November, 4, 2018.
Simmons, D. Mick, J., Graves, K., & Martin, S. K. (2008). 26,000 close call reports: Lessons from the University of Texas Close Call Reporting.
- Who developed and manages Whoops!?
Whoops! was developed by the following interdisciplinary team of researchers including the following individuals:
Dr. Stephanie C. Payne, Professor of Psychology
Dr. D. Benny Holland, Special Projects Manager, Clinical Learning Resource Center
Dr. Jose Hernandez, Assistant Professor of Pharmacy
Dr. Angela Mulcahy, Clinical Assistant Professor of Nursing
Mr. Stefan Dumlao, Psychology doctoral student
- Why was Whoops! developed?
Whoops! was developed to expose TAMHSC students to a near miss reporting system, to promote a culture of reporting early in the medical education process, and to provide medical personnel, especially students, with a safe means to practice reporting. It also promotes best practice in medicine at TAMHSC. By presenting data back to the all stakeholders it also encourages learning from mistakes, identifying systemic issues, and closes the loop on the process of reporting.
Near miss and error reporting systems are very common in industries outside of healthcare including nuclear, aviation, and oil & gas. For example, the Federal Aviation Administration developed the Aviation Safety Action Program (ASAP) over 20 years ago for all commercial aviation personnel (pilots, flight attendants, ground crew) to anonymously report safety issues and events. Each year, thousands of reports are submitted, even now, over 20 years later.
Whoops was also developed in the context of a research project to determine if people who submitted reports experienced an increase in their self-efficacy for reporting. The development of Whoops was supported by a seed grant from the TAMU College of Liberal Arts and approved by the Institutional Review Board #2018-0926D. Therefore, consistent with rules governing human subjects research, all reporting into the system should be discretionary. There is also an option to select “Do not use my responses – I am just submitting a test report” at the end of the report if you change your mind or are just exploring the system.
- What is a near miss?
A near miss is an event or circumstance that could have resulted in an accident or injury to the patient or healthcare provider/professional, but did not, either by chance or through timely intervention. Some examples include:
- failing to check/confirm a patient’s identification information on their armband
- dispensing too much medication
- not wearing gloves when drawing blood
- administering the wrong dose of a medication
- forgetting to put down the breaks on a gurney
- lifting a patient from the floor without bending one’s knees or seeking help
- How do near miss reporting systems prevent future incidents?
Many safety activities are reactive and not proactive, and some organizations wait for errors to occur before taking steps to prevent a recurrence. Near miss incidents often errors but may be overlooked as there was no harm (no injury, damage, or loss). An organization may not have a reporting culture where employees are encouraged to report these close calls. Thus, many opportunities to prevent errors. History has shown repeatedly that most errors were preceded by warnings or near miss incidents. Recognizing and reporting near miss incidents can significantly improve worker safety and enhance an organization’s safety climate.
- How is Whoops! different from the Safe Students Report (SSR)?
The National Council of State Boards of Nursing (NCSBN) oversees the Safe Students Report system which gathers errors, near misses, and other issues that occur in both clinical settings with real patients and in simulations for nursing schools across the globe. Data entered in this system are owned by NCSBN and compared to data entered by other schools. In short, there are three primary differences between Whoops! and SSR: (1) who owns the data and manages the system, (2) who reports, and (3) what is reported.
Who and When to Report
- Who should report near misses in Whoops!?
Anyone can report. TAMHSC faculty, students, staff, and standardized patients are all encouraged to report.
- What if someone else said they would report the event? Should I still report?
Yes, the system was designed for the purpose of giving people the opportunity to practice reporting, so we would rather more than one person report the same near miss than no one report it.
- When should I enter a report in Whoops!?
The system is designed anticipating that reporters would enter a report shortly after experiencing or witnessing a near miss. Since this means you are relying on your memory, it would be ideal to do report within 24 hours of the event; however, there is no time limit. The system can be easily accessed and completed using a smart phone.
- How long will it take to report a near miss in Whoops?
The form was designed to be relatively short with skip logic/branching of questions. On average it takes about 8 minutes to complete a report. That said, we encourage you to provide as much detail as possible to ensure the data are meaningful.
Note below the difference in the following 3 descriptions of the same incident that were entered into Whoops! The last one is the most informative as it reveals more details about the error and possibly why it occurred (similar drug names), as well as outcomes that resulted from the error.
- Wrong medication
- Navene was given instead of Norvasc, resulting in fall for to light headedness
- Patient (71 y.o. female with HTN) received incorrect medication from a pharmacist. This led to an episode of light-headedness and a fall. Pt received Navane (Thiothixene), an anti-psychotic, instead of Norvasc (amlodipine).
What to report
- What should be/is reported?
Ideally all near misses in the simulation context are reported. Again, a near miss is an event or circumstance that could have resulted in an accident or injury to the patient or healthcare provider/professional, but did not, either by chance or through timely intervention.
Whoops! is structured with specific questions and multiple choice response options. A copy of the questions in the form of an example report can be accessed here. Briefly, you will be asked a few questions about the event (date, location), factors that contributed to the event, and things that can be done to avoid having the event occur in the future.
- What should NOT be reported?
Medical errors and near misses with real patients should not be reported in Whoops! as this system is not housed on a Health Insurance Portability and Accountability Act (HIPAA)-compliant server.
- What has been reported? What happens to the data?
At the end of each semester (December, May, August), we will summarize the data reported and create a summary and post it here. We encourage all stakeholders to review the summary of the data and reflect on patterns in the data. This information can be used to modify and develop new simulation scenarios and identify learning opportunities.
- As a faculty member/instructor, how can I use Whoops! to teach my students about patient safety and reporting?
We have developed a brief script for instructors to read to their class before going to the CLRC to promote reporting of any close calls that occur during simulations. Some faculty have also encouraged students to report errors they read about or view in a video into the system. Because the reporting system is a part of a research study, students should not be required to use the system.
- Can I have a copy of my report?
Yes, after you submit, the system automatically presents a summary of your report. You can then click on the button to create a pdf of your report to save and/or print. This can be a useful way to document your efforts.
Confidentiality
- Who will see my report? Who has access to the data?
To a certain extent, Whoops! is intended to be a simulation of a reporting system used in the real world (hospitals, pharmacies, etc.). Consistent with that, it should be a psychologically safe environment for reporting. In other words, it should be low-stakes with no adverse consequences associated with submitting a report and contribute to the formative educational experience. Therefore, only the research team listed above will have access to the data. No personally identifying information is requested in the form, so your identity is protected.
- Will I get in trouble for reporting?
No. Whoops! was designed to be a non-punitive learning tool.
- Will I get in trouble for not reporting?
No.
- Why report near miss in Whoops!?
In practice, medical errors cost lives, and a near miss may be the only warning practitioners have before a much more serious error occurs. Reports are anonymous and only take a few minutes. By practicing this in a simulation environment, we get used to it and it becomes the norm. Learning from near misses is more likely to occur when we report them, share with others, and track them over time.
- What if I have other questions not listed here?
You are welcome to submit unanswered questions and suggestions for improvement to Dr. Stephanie C. Payne at scp@tamu.edu.