Blameless Patient Safety Initiative Summary
QUESTION 1
Introduction
Morath drove and initiated the Patient Safety Initiative at Children’s Hospital and Clinics by transforming mindsets and culture within the hospital. Key initiatives implemented by her included (a) Introduction of a Blameless Patient Safety Reporting System (b) Conducting Focus Groups and (c) Setting up of Patient Safety Steering Committee.
Building Block 1: A supportive learning environment (key activities implemented, key challenges and effectiveness of endeavor)
1.1 Psychological Safety
1.1.1 Blameless Patient Safety Reporting System
Morath introduced a Blameless Patient Safety Reporting System for recording medical errors, where employees were allowed to communicate confidentially and anonymously …show more content…
For instance, minutes of “sequence of events interviews” were taken. This ensured that information is consolidated and properly managed.
2.2.2 Patient Safety Initiative
Upon joining the hospital, Morath launched the Patient Safety Initiative, whereby she garnered inputs and suggestions from key personnel in the hospital to ensure that the strategy devised is relevant and applicable in Children’s context.
Upon hiring an Innovation Manager, Morath began planning how to collect data on current safety standing. She started to gather data on current state of patient safety in conducting confidential focus groups. Challenge was in getting people to speak about the gaps in safety which bring emotions and memory.
2.3 Analysis
2.3.1 Focused Event Studies
PSSC, through Focused Events Studies, revised hospital processes, policies in conducting investigations. For example, these policies were to include cases of ‘near misses’. The studies involved identification, understanding the proper documentation of event sequences. Study team even started to experiment involving 2 facilitators: one to facilitate and the other to observe non-verbal behavior to ensure that a complete picture was …show more content…
Effectiveness
o Many employees took advantage of this opportunity to learn about the science of improving safety in complex systems.
Patient Safety Steering Committee (PSSC)
Appointed and chaired the Patient Safety Steering Committee (PSSC) which comprised various parties such as physicians, doctors, nursing union leaders and parents. Through PSSC, common goals of safety initiatives were set; inputs were invited from the various participants of the PSSC. Multiple points of view were encouraged and the participants identified the problems and challenges and found solutions for them, such as the Patients Safety Report and Focused Event Analysis. PSSC also reviewed the findings from accident inquiries and monitored the progress of safety initiative.
Challenges
o Lack of resources to implement the improvements suggested from the committee. o Difficulty in quantifying the effectiveness of initiatives from PSSC, Hence, justification of benefits versus opportunity costs incurred was not strong.
Introduction
Morath drove and initiated the Patient Safety Initiative at Children’s Hospital and Clinics by transforming mindsets and culture within the hospital. Key initiatives implemented by her included (a) Introduction of a Blameless Patient Safety Reporting System (b) Conducting Focus Groups and (c) Setting up of Patient Safety Steering Committee.
Building Block 1: A supportive learning environment (key activities implemented, key challenges and effectiveness of endeavor)
1.1 Psychological Safety
1.1.1 Blameless Patient Safety Reporting System
Morath introduced a Blameless Patient Safety Reporting System for recording medical errors, where employees were allowed to communicate confidentially and anonymously …show more content…
For instance, minutes of “sequence of events interviews” were taken. This ensured that information is consolidated and properly managed.
2.2.2 Patient Safety Initiative
Upon joining the hospital, Morath launched the Patient Safety Initiative, whereby she garnered inputs and suggestions from key personnel in the hospital to ensure that the strategy devised is relevant and applicable in Children’s context.
Upon hiring an Innovation Manager, Morath began planning how to collect data on current safety standing. She started to gather data on current state of patient safety in conducting confidential focus groups. Challenge was in getting people to speak about the gaps in safety which bring emotions and memory.
2.3 Analysis
2.3.1 Focused Event Studies
PSSC, through Focused Events Studies, revised hospital processes, policies in conducting investigations. For example, these policies were to include cases of ‘near misses’. The studies involved identification, understanding the proper documentation of event sequences. Study team even started to experiment involving 2 facilitators: one to facilitate and the other to observe non-verbal behavior to ensure that a complete picture was …show more content…
Effectiveness
o Many employees took advantage of this opportunity to learn about the science of improving safety in complex systems.
Patient Safety Steering Committee (PSSC)
Appointed and chaired the Patient Safety Steering Committee (PSSC) which comprised various parties such as physicians, doctors, nursing union leaders and parents. Through PSSC, common goals of safety initiatives were set; inputs were invited from the various participants of the PSSC. Multiple points of view were encouraged and the participants identified the problems and challenges and found solutions for them, such as the Patients Safety Report and Focused Event Analysis. PSSC also reviewed the findings from accident inquiries and monitored the progress of safety initiative.
Challenges
o Lack of resources to implement the improvements suggested from the committee. o Difficulty in quantifying the effectiveness of initiatives from PSSC, Hence, justification of benefits versus opportunity costs incurred was not strong.