Making Sense of System- Based Safety
|
|
- Barnard Stevenson
- 5 years ago
- Views:
Transcription
1 Making Sense of System- Based Safety Angela Gibbs, Inland Hospital Madeline Orange, Maine Sentinel Event Team Joe Katchick, Maine Sentinel Event Team Jeff Brown, Maine Primary Care Association Patient Safety Organization USM Patient Safety Academy September 29, 2017
2 1.A System Model 2.Accidents as decision side effects 3.Just culture 4.A case for your review
3 A system model: people are a system component Institute of Medicine. (2011) Health IT and Patient Safety: Building Safer Systems for Better Care. Pages Accessed January 22, Systems-for-Better-Care.aspx.
4 A System of Systems: Nested Levels of the U.S. Healthcare System D C Payors Healthcare Organization B A Patient Experience Front-line units Legislation Clinical Space Berwick, D., A User s Manual for the IOM s Quality Chasm Report, Corrigan, et al., 2001
5 Accidents as Decision Side Effects Judith s story: Morphine Misadventures BCMA Meets Cost Pressure Patankar, Brown, Treadwell, 2005
6 D The U.S. Healthcare System s Cascade of Decision Side-effects C A B Clinical Space
7 Payments D Tort Law Legislation The U.S. Healthcare System s Cascade of Decision Side-effects C Cost Cutting Focus on Efficiency B A Clinical Space
8 Payments D Tort Law Legislation The U.S. Healthcare System s Cascade of Decision Side-effects C Fragmentation of care processes. Slips Lapses Mistakes... Cost Cutting Focus on Efficiency B Understaffing Time Pressure Fatigue A Clinical Space 11
9 Payments D Tort Law Legislation The U.S. Healthcare System s Cascade of Decision Side-effects C Fragmentation of care processes. Slips Lapses Mistakes... Cost Cutting Focus on Efficiency B Understaffing Time Pressure Fatigue Adverse Event A Clinical Space
10 Payments D Tort Law Legislation Judith s Story C New facility planned Cost cutting Focus on efficiency Normalized risk; unsafe behavior B Slips Lapses Mistakes... Time pressure, nominal workflow interrupted, unworkable procedure, inadequate # scanners.. Heightened potential for an adverse event Clinical Space A
11 Organizational Learning, Forgetting and The Functioning of Frontline Units Over Time Reliability Bankruptcy Latent Conditions Balance Latent Conditions Latent Conditions Adverse Outcome Efficiency Adapted from Managing the Risk of Organizational Accidents, J. Reason, 1997
12 Dampening the Accident See-Saw Sensitive Surveillance, CSE Investigation, and Corrective Action Reliability Bankruptcy Latent Conditions Balance Latent Conditions Latent Conditions Adverse Outcome Efficiency Adapted from Managing the Risk of Organizational Accidents, J. Reason, 1997
13 A Safety Management System Continual Surveillance: Detection, Identification, Corrective Response, Monitoring for Effect Changes Accelerated in clinical resources, tasks, Org. Response processes, tools Correction Goal conflicts, Constraints Adaptations, Workarounds, Normalized risk.. Near misses Injury or Death Proactive feedback loops Reactive Feedback Loops Early Identification and Management of Emergent Risk and Hazard in Clinical Space 1. Detection via Risk Triggers, Team Debriefing and Feedback, Safety Reports 2. Clinically situated investigation using the socio technical system lens (CSE methods) 3. Development of corrective action using investigative findings 4. Monitoring for intended and unintended effects 5. Ongoing surveillance, problem detection, and rapid cycle improvement
14 The system of interest for the improvement of patient safety is defined not by the business affiliations of providers, but by patient pathways within and among provider facilities, and by the information exchange that attends that patients care.
Response to Safety Events Just Culture HR Policy 5.24 Page 1 of 10
Response to Safety Events Just Culture HR Policy 5.24 Page 1 of 10 Policy : 5.24 Subject: Supersedes: Effective: October 8, 2008 Revised: July 1, 2002, December 1, 2012 Reviewed: December 1, 2012 Response
More informationTHE AMERICAN BOARD OF PATHOLOGY PATIENT SAFETY COURSE APPLICATION
THE AMERICAN BOARD OF PATHOLOGY PATIENT SAFETY COURSE APPLICATION Requirements: Component I Patient Safety Self-Assessment Program Programs must meet the following criteria to be an ABP approved Patient
More informationCOOK COUNTY HEALTH & HOSPITALS SYSTEM
COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee Quality and Reliability in Health Care Krishna Das, MD, Chief Quality Officer 15 March 2016 Quality:
More informationUnit Based Culture of Safety and Learning. Owensboro Health March, 2017
Unit Based Culture of Safety and Learning Owensboro Health March, 2017 Owensboro Health 477 Bed Regional Hospital 32 Bed ICU 30 Transitional Care Beds Level III Trauma Center Level III NICU Largest employer
More informationSelf-Assessment Questionnaire: Establishing a Health Information Technology Safety Program
Self-Assessment Questionnaire: Establishing a Health Information Technology Safety Program Initial assessment by: Date: In consultation with: Date of previous assessment: The success of a health information
More informationMedication Safety in LTC. Objectives. About ISMP Canada
Medication Safety in LTC Part II -Vulnerabilities in the Medication Use Process and Strategies to Enhance Medication Safety Lynn Riley, RN ISMP Canada Thursday, October 20, 2011 Objectives At the end of
More informationThe Importance of Transfusion Error Surveillance This is step #1 in error management. Jeannie Callum, BA, MD, FRCPC, CTBS
The Importance of Transfusion Error Surveillance This is step #1 in error management Jeannie Callum, BA, MD, FRCPC, CTBS 6051 Clinical Errors 9083 Laboratory Errors 15134 Errors over 6 years I don t want
More informationA9/B9: Integrating Patient Safety into Your System s DNA
A9/B9: Integrating Patient Safety into Your System s DNA Doug Bonacum Frank Federico A9 Moderator: Abdulaziz Darwish B9 Moderator: Ibrahim Fawzy Hassan Saturday 26th April A9: 11:00 12:15 B9: 13:30 14:45
More informationSafety Measurement, Monitoring & Strategies
Safety Measurement, Monitoring & Strategies Jonkoping Microsystem Festival Scientific Day March 2016 Charles Vincent Professor of Psychology University of Oxford Lead Oxford AHSN Patient Safety Collaborative
More informationDesigning for Safety
2014 FGI Guidelines Update Series FGI Guidelines Update #1 July 11, 2013 Designing for Safety Ellen Taylor, AIA, MBA, EDAC In 2010 one of the topics introduced to the Guidelines for Design and Construction
More informationSetting: Emergency departments are high-risk contexts; they are over-crowded and
QUALITY IMPROVEMENT STUDENT PROJECT PROPOSAL: IMPROVING HANDOFFS IN SAN FRANCISCO GENERAL HOSPTITAL S EMERGENCY DEPARTMENT TMIT Student Projects QuickStart Package 1. BACKGROUND Setting: Emergency departments
More informationReviewing Methods Used in Patient Safety Research: Advantages and Disadvantages. This SPSRN work is funded by
Reviewing Methods Used in Patient Safety Research: Advantages and Disadvantages Dr Jeanette Jackson (j.jackson@abdn.ac.uk) This SPSRN work is funded by Introduction Effective management of patient safety
More informationHuman Factors and Ergonomics in Health Care and Patient Safety
Human Factors and Ergonomics in Health Care and Patient Safety Pascale Carayon, Ph.D. Procter & Gamble Bascom Professor in Total Quality Department of Industrial and Systems Engineering Director of the
More informationPatient Safety Incident Report Form
Page 1 This form is not meant to be a substitute to the health region s incident reporting. The purpose of this form is to assist with the identification and management of adverse events and near misses;
More informationVarious Views on Adverse Events: a collection of definitions.
Various Views on Adverse Events: a collection of definitions. April 20, 2008 Werner CEUSTERS a,1, Maria CAPOLUPO b, Georges DE MOOR c, Jos DEVLIES c a New York State Center of Excellence in Bioinformatics
More informationCulture of Safety: What s in Your Toolbox?
Culture of Safety: What s in Your Toolbox? Kathy Ghomeshi, PharmD, BCPS Medication Safety Specialist Victoria Serrano Adams, PharmD, FASHP, FCSHP Director of Pharmaceutical Services UCSF Medical Center
More informationPreventing Medical Errors
Presents Preventing Medical Errors Contact Hours: 2 First Published: March 31, 2017 This Course Expires on: March 31, 2019 Course Objectives Upon completion of this course, the nurse will be able to: 1.
More informationHow Should Policy Reflect a Culture of Safety?
How Should Policy Reflect a Culture of Safety? BETA Healthcare Group BETA HEART Domain I: Culture of Safety All Rights Reserved 2016 Table of Contents How Should Policy Reflect a Culture of Safety?...
More informationJust Culture. The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.
Just Culture November 2016 Just Culture The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes. Dr Lucian Leape Harvard School of Public
More informationDesign Principles for Learning and Caring in Patient-Centered Primary Care Homes
The H.R. Bob Brettell, MD, Memorial Lectureship January 29, 2013 Design Principles for Learning and Caring in Patient-Centered Primary Care Homes Judith L. Bowen, MD, FACP Professor of Medicine Oregon
More informationRisk Management and Safety in Health Care Organizations
Risk Management and Safety in Health Care Organizations Fadi El-Jardali, MPH, PhD November 1, 2016 Day 1 1 Objectives Increase knowledge about concepts of safety and risk management in health care organizations
More informationInnovations for Integrating Quality and Safety in Education and Practice: The QSEN Project
Innovations for Integrating Quality and Safety in Education and Practice: The QSEN Project Linda Cronenwett, PhD, RN, FAAN Principal Investigator, QSEN Gwen Sherwood, PhD, RN, FAAN Co-Investigator, QSEN
More informationECRI Patient Safety Organization HFACS and Healthcare
October 15, 2015 ECRI Patient Safety Organization HFACS and Healthcare Thomas W. Diller, MD, MMM VP System Chief Medical Officer CHRISTUS Health Learning Objectives Understand the human factors errors
More informationEvidence-Based Quality Improvement: A recipe for improving medication safety and handover of care Smeulers, Marian
UvA-DARE (Digital Academic Repository) Evidence-Based Quality Improvement: A recipe for improving medication safety and handover of care Smeulers, Marian Link to publication Citation for published version
More informationBuilding a High-Performance team in the Pediatric Medical Home Xavier Sevilla M.D. FAAP Whole Child Pediatrics MCRHS Inc.
Building a High-Performance team in the Pediatric Medical Home Xavier Sevilla M.D. FAAP Whole Child Pediatrics MCRHS Inc. Whole Child Pediatrics Whole Child Pediatrics Opened November 2007 Using the Principles
More informationCommunication Among Caregivers
Communication Among Caregivers October 2015 John E. Sanchez - MS, CPHRM, Pendulum, LLC Amid the incredible advances, discoveries, and technological achievements in healthcare, one element has remained
More information2/15/2016. To Err is Human. Patient Safety in OB/GYN: Current Trends. At the conclusion of this talk. Published by IOM in 1999
Patient Safety in OB/GYN: Current Trends Joseph R. Biggio Jr., MD Objectives At the conclusion of this talk Comprehend the underlying rationale for the increasing emphasis on patient safety Understand
More informationWhat Every Patient Safety Officer Must Know:
What Every Patient Safety Officer Must Know: Tapping into the Best Resources in the Country John R. Combes, MD Senior Medical Advisor Hospital and Healthsystem Association of Pennsylvania Harrisburg, PA
More informationHealth Management Information Systems: Computerized Provider Order Entry
Health Management Information Systems: Computerized Provider Order Entry Lecture 2 Audio Transcript Slide 1 Welcome to Health Management Information Systems: Computerized Provider Order Entry. The component,
More informationOrganizing patient safety research to identify risks and hazards ...
ii2 Organizing patient safety research to identify risks and hazards J B Battles, R J Lilford... Patient safety has become an international priority with major research programmes being carried out in
More informationThe Purpose and Goals of Risk Management in the Sleep Center. Melinda Trimble, RPSGT, RST, LRCP
The Purpose and Goals of Risk Management in the Sleep Center Melinda Trimble, RPSGT, RST, LRCP Objectives Overview of Risk Management as a concept What is the purpose of Risk Management and what are its
More informationA culture of safety is a culture of compassion
A culture of safety is a culture of compassion Compassion in Action Webinar Series March 21, 2017 1 Moderator Andrea Greenberg Communications and Partnerships Associate The Schwartz Center for Compassionate
More informationCommunication and Teamwork for Patient Safety 1.0 Contact Hour Presented by: CEU Professor
Communication and Teamwork for Patient Safety 1.0 Contact Hour Presented by: CEU Professor 7 www.ceuprofessoronline.com Copyright 8 2008 The Magellan Group, LLC All Rights Reserved. Reproduction and distribution
More information21 Questions. Key risks (other) 9. related to finances? related to leadership?
21 Questions Guidance for healthcare boards on what they should ask senior leaders about risk. Drawing on strong ethical and evidence-based principles, HIROC, in collaboration with subscribers, has developed
More informationPATIENT SAFETY ORGANIZATION TERMINOLOGY AND ACRONYMS
PATIENT SAFETY ORGANIZATION TERMINOLOGY AND ACRONYMS Active Error An error that occurs at the point of contact. Active errors are generally readily apparent (e.g., pushing an incorrect button, ignoring
More informationAligning Surgical Pathology & Informatics to Promote Patient Safety
Aligning Surgical Pathology & Informatics to Promote Patient Safety labinfotech infotechsummit April 11, 2008 Jeffrey L. Myers, M.D. A. James French Professor & Director, Anatomic Pathology University
More information9/9/2016. How Respiratory Therapist Enhance Patient Safety. Introduction. Raise your hand. Tawana Shaffer CPHRM, MBA, BSc, CRT
How Respiratory Therapist Enhance Patient Safety Tawana Shaffer CPHRM, MBA, BSc, CRT Introduction Raise your hand 1 How do you define Patient Safety? What is Patient Safety? Communication Care Falls Outcomes
More informationShifting from Blame-&-Shame to a Just-and-Safe Culture
Shifting from Blame-&-Shame to a Just-and-Safe Culture Barb Sproll Medication Safety Pharmacist Winnipeg Regional Health Authority 29 May 2018 Conflict of Interest I have no conflicts to disclose. Objectives:
More informationHealth Management Information Systems
Health Management Information Systems Computerized Provider Order Entry (CPOE) Computerized Provider Order Entry (CPOE) Learning Objectives 1. Describe the purpose, attributes and functions of CPOE 2.
More informationA GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES
A GLOWING RESEMBLANCE A COMPARE AND CONTRAST OF MEDICAL AND NUCLEAR PERFORMANCE IMPROVEMENT INITIATIVES 23 rd Annual HPRCT Conference June 12-15, 2017 Thomas Diller, MD, MMM; Executive Director University
More informationLEADERSHIP CHALLENGES IN PATIENT SAFETY
LEADERSHIP CHALLENGES IN PATIENT SAFETY Kenneth W. Kizer, MD, MPH. California Hospital Patient Safety Organization Annual Meeting Sacramento, CA April 8, 2013 Presentation Charge Discuss some of the challenges
More informationHigh-Reliability Safety During Emergency Operations 2017B014
High-Reliability Safety During Emergency Operations 2017B014 C O R Y W O R D E N, M S, C S H M, C S P, C H S P, A R M, R E M, C E S C O A N D K E L L E Y L O M B A R D O, M. E D, U S A F M A S T E R I
More informationMidwest Alliance for Patient Safety Patient Safety Organization Getting Started with a PSO. An Illinois Hospital Association Company
Midwest Alliance for Patient Safety Patient Safety Organization Getting Started with a PSO An Illinois Hospital Association Company Today s Roadmap Objectives: 1. Explain the PSQIA and PSO Basics 2. Learn
More informationNational Patient Safety Agency Root Cause Analysis (RCA) Investigation
National Patient Safety Agency Root Cause Analysis (RCA) Investigation Margaret O Donovan Assistant Director for Acute Services Types of failure Active failures - slips, lapses, fumbles, mistakes, procedural
More informationQAPI- CREATING A CULTURE FOR IMPROVMENT Guide to the Basic Principles of Quality Improvement. Patty Austin, RN, CPHQ Project Coordinator
QAPI- CREATING A CULTURE FOR IMPROVMENT Guide to the Basic Principles of Quality Improvement Patty Austin, RN, CPHQ Project Coordinator QA + PI = QAPI QAPI takes a systematic, comprehensive, and data-driven
More informationLiz Gombash Executive Director, Strategic Grants Planning and Development, Seminole State College of Florida
Liz Gombash Executive Director, Strategic Grants Planning and Development, Seminole State College of Florida Dallas County Community College District Dallas, TX May 4, 2012, 1:30 PM 2:30 PM Note: This
More informationSafetyNET RX. Continuous Quality Assurance in Nova Scotia Community Pharmacies
SafetyNET RX Continuous Quality Assurance in Nova Scotia Community Pharmacies Objectives Discuss continuous quality improvement in the context of community pharmacy practice Explain the SafetyNET Rx process
More informationBreakfast With the Chiefs December 15, 2005 Philip Hassen, CEO, CPSI
Reflections: Ten Months and Where to From Here Breakfast With the Chiefs December 15, 2005 Philip Hassen, CEO, CPSI 1 Presentation Overview Nature of the Problem Safer Healthcare Now Campaign Systems vs.
More informationSTATEMENT. JEFFREY SHUREN, M.D., J.D. Director, Center for Devices and Radiological Health Food and Drug Administration
STATEMENT JEFFREY SHUREN, M.D., J.D. Director, Center for Devices and Radiological Health Food and Drug Administration Institute of Medicine Committee on Patient Safety and Health Information Technology
More informationA Single Culture of Safety
December 8, 2015 Workers and Patients: A Single Culture of Safety :: Helen Archer-Duste, RN, MS Executive Director, Workplace Safety and Care Experience Northern California :: Molly Clopp, RN, MS, MBATM,
More informationCreating a Highly Reliable Health System: the Leadership Challenge. 6 th Annual Patient Safety Symposium Rick Foster, MD
Creating a Highly Reliable Health System: the Leadership Challenge 6 th Annual Patient Safety Symposium Rick Foster, MD April 18, 2013 Moving Toward Zero It may seem a strange principle to enunciate as
More informationPatient Safety. Annual Accidental Deaths. Medical Errors in History. How Hazardous Is Health Care (Amalberti)
Patient Safety Annual Accidental Deaths 100000 90000 80000 70000 60000 50000 40000 30000 20000 10000 0 Medical Auto Workplace Air Deaths Total lives lost per year How Hazardous Is Health Care (Amalberti)
More informationHow BPOC Reduces Bedside Medication Errors White Paper
How BPOC Reduces Bedside Medication Errors White Paper July 2008 Brad Blackwell, M.S., R.Ph. Eloise Keeler, R.N., B.S.N. Abstract Medication errors are a significant source of harm to patients in U.S hospitals,
More informationIncident Investigation
Incident Investigation Richard Kohlhausen, Capital Risk Management Ronald Sawchak, ARM CNA Insurance Companies Slide 1 Welcome Incident investigation is a core safety program element Program overview Focus
More informationUnderstanding the High Reliability Organization and Why It's Important to Your Lab
Understanding the High Reliability Organization and Why It's Important to Your Lab Jennifer Rhamy MBA, MA, MT(ASCP)SBB, HP Executive Director, Laboratory Accreditation High Reliability Organization (HRO)
More informationPatient Safety Culture Bundle for CEOs & Senior Leaders. Presenters: Chris Power, Polly Stevens, Alex Munter, Linda Hughes
Patient Safety Culture Bundle for CEOs & Senior Leaders Presenters: Chris Power, Polly Stevens, Alex Munter, Linda Hughes @NHLC2018 #NHLC2018 Patient Safety Culture Bundle for CEOs & Senior Leaders National
More informationADMINISTRATIVE POLICY & PROCEDURE PATIENT SAFETY PLAN
PAGE #: 1 of 6 CROSS REFERENCES: Administrative Policy PI-01: Administrative Policy PI-03: Administrative Policy RI-20: Administrative Policy EC-25: Sentinel Event Risk Management Plan Guidelines for Disclosure
More informationSharps Safety Awareness
Sharps Safety Awareness American University of Beirut 14 June 2013 Role of JCI to Improve Safety Culture and Quality of Health Care in the Middle East Khalil Rizk, BSN, MPH, MA, CPHQ JCI Consultant 0 What
More informationAssessing and improving the use of near-miss reporting to prevent adverse events and errors in rural hospitals
Assessing and improving the use of near-miss reporting to prevent adverse events and errors in rural hospitals John M. Kessler, B.S. Pharm., Pharm. D. Steve C. Dedrick, MS Pharm. NCCMedS Project Directors
More informationHuman Factors Engineering in Health Care. Awatef O. Ergai, PhD Post-Doctoral Research Associate Healthcare Systems Engineering Institute
Human Factors Engineering in Health Care Awatef O. Ergai, PhD Post-Doctoral Research Associate Outline 1. What s human factors engineering (HFE) 2. Why is human factors engineering important in health
More informationObjectives. Key Elements. ICAHN Targeted Focus Areas: Staff Competency and Education Quality Processes and Risk Management 5/20/2014
ICAHN Targeted Focus Areas: Staff Competency and Education Quality Processes and Risk Management Matthew Fricker, RPh, MS, FASHP Program Director, ISMP Rebecca Lamis, PharmD, FISMP Medication Safety Analyst,
More informationThe Human Factor: Applying Safety Science in Health Care
The Human Factor: Applying Safety Science in Health Care Sarah Henrickson Parker, PhD Director of Education and Academic Affairs, Research Scientist National Center for Human Factors Engineering in Healthcare
More informationUniversity of Iowa Hospitals and Clinics (UIHC) DEPARTMENT OF NURSING SERVICES AND PATIENT CARE QUALITY PLAN Office of Nursing Quality
University of Iowa Hospitals and Clinics (UIHC) DEPARTMENT OF NURSING SERVICES AND PATIENT CARE QUALITY PLAN 2013-2014 Office of Nursing Quality Philosophy The Department of Nursing Services and Patient
More informationWireless Networks & Point of Care Technology: Implications for Interdisciplinary Collaboration
Wireless Networks & Point of Care Technology: Implications for Interdisciplinary Collaboration Kathryn G. Sapnas, PhD, RN, CCRN, CNOR Wayne G. Martin, MS, RN, Thomas Shelton, MS, RN Kevin Hope, BS, Kathryn
More informationAdministrative Policies and Procedures
Administrative Policies and Procedures Originating Venue: Environment of Care Policy No.: EC 2007 Title: Environment of Care Management Program Cross Reference: EC 2001 Date Issued: 04/14 Authority Environmental
More informationKick Start Your QI Using Defect Analysis for a Successful Resident Quality Improvement Curriculum
Kick Start Your QI Using Defect Analysis for a Successful Resident Quality Improvement Curriculum Muhamad Elrashidi, M.D. Megan Krause, M.D. Joe Skalski, M.D. Mike Wilson, M.D. Chief Medicine Residents
More informationAn Integrated Approach to Promoting Workplace Health and Wellbeing: Benefits and Challenges
An Integrated Approach to Promoting Workplace Health and Wellbeing: Benefits and Challenges 21 st Annual Health Promotion Conference Promoting Workplace Health and Wellbeing National University of Ireland
More informationPREP the Course 2017 St. Petersburg, FL General Pediatrics Session II
PREP the Course 2017 St. Petersburg, FL General Pediatrics Session II The speaker has no conflicts of interest to disclose. No commercial support No discussion of off-label usage of drugs or devices/equipment
More informationNational Institute for Forest Products Innovation Mount Gambier Hub
National Institute for Forest Products Innovation Mount Gambier Hub Call for Project Proposals Briefing Document Research and Development Projects - Round 1 Program Objective The Mount Gambier hub of the
More informationUsing Evidence to Support the Business Case the route to adoption
Using Evidence to Support the Business Case the route to adoption Christopher P Price Department of Primary Care Health Sciences University of Oxford Technology Adoption in Healthcare innovation improving
More informationGuidelines for Managing Pharmacy Systems for Quality and Safety November 2002
November 2002 Guidelines for Managing Pharmacy Systems for Quality and Safety Background The Australian Council for Safety and Quality in Health Care (ACSQHC) was established by Australian Health Ministers
More informationJourney to an Effective Safety Culture Part I of III Exploring the Role of Culture in Safety Outcomes. Embracing Patient Safety Culture
White Paper Journey to an Effective Safety Culture Part I of III Exploring the Role of Culture in Safety Outcomes Embracing Patient Safety Culture What is the Purpose of this Series? The purpose of this
More informationThe Road to Clinical Transformation
The Road to Clinical Transformation Ann O Brien RN MSN CPHIMS Kaiser Permanente Senior Director Clinical Informatics KPIT & National Patient Care Services Learning Objectives 1. Describe strategies to
More informationFrontline Improvement Using Defect Analysis March 9, 2012 R Resar, MD; N Romanoff, MD, MPH; A Majka, MD; J Kautz, MD; D Kashiwagi, MD; K Luther, RN
Frontline Improvement Using Defect Analysis March 9, 2012 R Resar, MD; N Romanoff, MD, MPH; A Majka, MD; J Kautz, MD; D Kashiwagi, MD; K Luther, RN Introduction More than a decade ago, the Institute of
More informationUsing Transparency to Drive Patient Safety
Session Code These presenter s have nothing to disclose Using Transparency to Drive Patient Safety Doug Salvador, MD MPH Chief Quality Officer, Baystate Health Chief Medical Officer, Baystate Medical Center
More informationYoder-Wise: Leading and Managing in Nursing, 5th Edition
Yoder-Wise: Leading and Managing in Nursing, 5th Edition Chapter 02: Patient Safety Test Bank MULTIPLE CHOICE 1. In an effort to control costs and maximize revenues, the Rehabilitation Unit at Cross Hospital
More informationNursing Informatics at the Forefront of Nursing April 12, 2015
Nursing Informatics at the Forefront of Nursing April 12, 2015 Pamela Cipriano, PhD, RN, NEA-BC, FAAN President, American Nurses Association DISCLAIMER: The views and opinions expressed in this presentation
More informationReducing the risk of serious medication errors in community pharmacy practice
Reducing the risk of serious medication errors in community pharmacy practice Eastern Medicaid Pharmacy Administrators Association (EMPAA) November 1, 2017 Newport, Rhode Island Michael R. Cohen, RPh,
More informationEffective. handoff ommunication CBy Kim K. Wheeler, MSN, RN, CNOR. 22 OR Nurse 2014 January 1.8
1.8 ANCC CONTACT HOURS Effective handoff ommunication CBy Kim K. Wheeler, MSN, RN, CNOR CCommunication breakdowns are one of the leading causes of medical errors. In a root cause analysis of over 4,000
More informationQuality Improvement Overview. Paul vanostenberg, DDS. MS Vice President Accreditation and Standards Joint Commission International
Quality Improvement Overview Paul vanostenberg, DDS. MS Vice President Accreditation and Standards Joint Commission International The History of Improving We are perfect! Get rid of the bad apples! System
More informationA23/B23: Patient Harm in US Hospitals: How Much? Objectives
A23/B23: Patient Harm in US Hospitals: How Much? 23rd Annual National Forum on Quality Improvement in Health Care December 6, 2011 Objectives Summarize the findings of three recent studies measuring adverse
More informationIncident Reporting Systems and Future Strategies for Patient Safety Improvement
WHITE PAPER: Incident Reporting Systems and Future Strategies for Patient Safety Improvement Author: Datix Date: 2016/17 Driving down harm How can healthcare providers most successfully pursue the goal
More informationYear in Review ro ils RO ILS
RO ILS RADIATION ONCOLOGY INCIDENT LEARNING SYSTEM Sponsored by ASTRO and AAPM Year in Review 2015 1 ro ils noun \ˈro i(-ə)ls\ Radiation Oncology Incident Learning System; a system to facilitate safer
More informationRCA in Healthcare 3/23/2017. Why Root Cause Analysis is Performed. Root Cause Analysis in Healthcare Part - 1. Contd. Contd.
Why Root Cause Analysis is Performed Root Cause Analysis in Healthcare Part - 1 Prof (Col) Dr R N Basu Executive Director Academy of Hospital Administration Kolkata Chapter The goal of the root cause analysis
More informationA Comprehensive Framework for Patient Safety
A Comprehensive Framework for Patient Safety A Framework for a System of Safety Objectives 1. Link safety to organizational strategy and resources 2. Define a culture of safety 3. Apply improvement methods
More informationMedication Errors An Opportunity to Improve
FSHP Medication Errors An Opportunity to Improve Laura Monroe-Duprey, BS Pharm, PharmD Joanie Spiro Stevens, PharmD, BCPS Disclosure Laura Monroe-Duprey - I do not have (nor does any immediate family member
More informationAnne Huben-Kearney, RN, BSN, MPA, CPHQ, CPHRM Assistant Vice President, Healthcare Risk Management AWAC Services, a member company of Allied World
Slide 1 Human Factors: The Science of Reliability MSHRM February 2015 Anne Huben-Kearney, RN, BSN, MPA, CPHQ, CPHRM Assistant Vice President, Healthcare Risk Management AWAC Services, a member company
More informationWalking the Tightrope with a Safety Net Blood Transfusion Process FMEA
Walking the Tightrope with a Safety Net Blood Transfusion Process FMEA AnMed Health AnMed Health, located in Anderson, South Carolina, is one of the largest and most technologically advanced health systems
More informationImplementing Surgeon Use of a Patient Safety Checklist in Ophthalmic Surgery
Report on a QI Project Eligible for Part IV MOC Implementing Surgeon Use of a Patient Safety Checklist in Ophthalmic Surgery Instructions Determine eligibility. Before starting to complete this report,
More information6/17/2014. Resilient health care: forging new directions. Australian Institute of Health Innovation s mission
Question 1: what s your definition of resilience, please? Resilient health care: forging new directions Australian Institute of Health Innovation Professor Jeffrey Braithwaite, PhD Professor of Health
More informationA Comprehensive Framework for Patient Safety
These presenters have nothing to disclose A Comprehensive Framework for Patient Safety Allan Frankel, MD and Carol Haraden, PhD 8 October 2015 A Framework for a System of Safety Objectives 1. Link safety
More information2. Why Applying Human Factors Is Important For Patient Safety
PATIENT SAFETY 436 TEAM 2. Why Applying Human Factors Is Important For Patient Safety Objectives: Understand Human Factors And Its Relationship To Patient Safety Define The Meaning Of The Term Human Factors
More informationBuilding a Safe Healthcare System
Building a Safe Healthcare System Objectives 2 Discuss the process of improving healthcare systems. Introduce widely-used methodologies in QI/PS. What is Quality Improvement? 3 Process of continually evaluating
More informationCaring For The Caregiver After Adverse Clinical Effects. Susan D. Scott, PhD, RN, CPPS University of Missouri Health Care System March 11, 2016
Caring For The Caregiver After Adverse Clinical Effects Susan D. Scott, PhD, RN, CPPS University of Missouri Health Care System March 11, 2016 University of Missouri Health Care University of Missouri
More informationEmbracing a Culture of Safety and Learning
Embracing a Culture of Safety and Learning Provincial Forum on Adverse Health Event Management St. John s Newfoundland May 26, 2008 Ward Flemons MD, FRCPC Vice-President, Health Outcomes Outline Adverse
More informationMedical Error Prevention
Medical Error Prevention Matthew Studenski, PhD September 9, 2016 Disclosures Nothing to disclose. 1 Medical Error Prevention Definition of a medical event Look back on human error assessment Current recommendations
More informationCreating High Reliability to Reduce Patient Harm
1 Creating High Reliability to Reduce Patient Harm Florida State University College of Medicine Center for Medicine and Public Health Tallahassee, FL Grand Rounds March 1, 2012 William Riley, Ph.D. Associate
More informationQuest for Excellence. Award Application. Bergan Mercy Medical Center Mercy Road. Omaha, Nebraska Contact:
Quest for Excellence Award Application Bergan Mercy Medical Center 7500 Mercy Road Omaha, Nebraska 68124 Contact: Gail Brondum, Operations Director Quality Management Services gail.brondum@alegent.org
More informationMarch Crossing The Quality Chasm, A New Health Care System For The 21 st Century An Overview
Crossing The Quality Chasm, A New Health Care System For The 21 st Century An Overview In March 2001, The Institute of Medicine (IOM), which was established by the National Academy of Sciences in 1970,
More informationWHAT HAVE WE MISSED IN ACHIEVING SAFER HEALTHCARE??
BMJ-IHI International Healthcare Forum, Singapore September 27-28, 2016 WHAT HAVE WE MISSED IN ACHIEVING SAFER HEALTHCARE?? Dr. / Akhil Sangal CEO Indian Confederation for Healthcare Accreditation Dr.
More information