Patient Safety Program
Safety Program Support
SAFETY CULTURE | COMMUNICATIONS | CLINICAL MANAGEMENT | MEDICATION MANAGEMENT | HEALTH INFORMATION TECHNOLOGY
Safety Culture
The Agency for Healthcare Research and Quality (AHRQ) in partnership with Premier Inc., the Department of Defense and the American Hospital Association developed a tool to assess the safety culture of a hospital as a whole, or specific units within hospitals, as well as to track changes in patient safety over time and evaluate the impact of patient safety interventions. Premier also developed a customized Excel™ data tool for easy entry and rapid display of results when using the AHRQ survey. Click here.
or http://www.premierinc.com/quality-safety/tools-services/safety/topics/culture/survey.js
NCPS Root Cause Analysis Tools
http://www.va.gov/ncps/CogAids/RCA/index.html
This guide functions as a cognitive aid to help teams in developing a chronological event flow diagram (an understanding of what occurred) along with a cause and effect diagram (why the event occurred). RCA teams have found this book an effective aid with these sometimes nettlesome activities
Just Culture
- Just Culture Primer
http://www.mers-tm.net/support/Marx_Primer.pdf - The Just Culture Community www.justculture.org
Boards on Board
Unit Safety Champions
AHRQ Employee Safety Culture Survey
Mistake-Proofing the Design of Health Care Processes
- http://www.ahrq.gov/qual/mistakeproof/
Journey to excellence: a system wide culture change begins with the board. Trustee.2004
Apr; 57(4):26-8, 1.
Safety Briefings
Engage front-line staff by increasing their awareness of patient safety issues and allowing them to share safety issues without fear of a punitive response. To find out more about Safety Briefings and how to implement them in your hospital, click here.
Patient Safety Leadership Walk Arounds
- What better way to show the staff of the leadership’s commitment to building an organizational culture focused on patient safety. To find out more about Leadership Walk-Arounds and how to implement, click here.
Arkansas Tool Share
Patient Safety Culture Game
The following game was developed by Glenna Laymon, RN.
Baptist Medical Center Heber Springs, AR
Purchase a Jenga (TM) game, make labels with excuses for patient care/safety (examples below)
- I’m too busy
- We don’t have an aide today
- The glove box was empty
- No report when transferring patient
- Didn’t check ID bracelet
Place a label on each Jenga block, take game to staff meetings for employees to play
Stack the blocks up (per game instructions), allow employees to remove blocks (per game instructions) until structure collapses
Goal: See how excuses can cause “holes” in patient care that can lead to disastrous results.
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| Patient Medication Safety Information Flyer | Partnership for Patient Safety Flyer |
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| Patient Safety: Be involved in your care Flyer | Safety First Program: It's OK to Ask!! Flyer |
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Patient Safety Newsletter Page 1 Developed by: Glenna Laymon RN at Baptist Medical Center Heber Springs |
Tarn, D. M., Heritage, Jl, Paterniti, D.A., Hays, R. D., Kravitz, R. L., Wenger, N. S.
(2006). Physician communication when prescribing new medications. Archives of Internal Medicine, 166(17), 1855-1862
SBAR Communication Tool
Most often, patient safety can be compromised when there is a gap in the communication between departments, between nurse and doctor or between transferring organizations. One way to ensure that key information is communicated would be to use a tool, which captures the current Situation, Background, Assessment and Recommendations. Click here.
Handoffs
Safety Briefings
- Engage front-line staff by increasing their awareness of patient safety issues and allowing them to share safety issues without fear of a punitive response. To find out more about Safety Briefings and how to implement them in your hospital, click here.
Time Outs
Wrong Site Surgeries
CUS Communications
Fall Prevention/Management
- VHA NCPS Fall Prevention and Management Tool
http://www.patientsafety.gov/CogAids/FallPrevention/index.html#
Following the assessment a team approach to initiate fall prevention interventions is recommended. If the patient is at risk for falls, this guide suggests interdisciplinary interventions that include medical, nursing, and rehabilitations management.
This Fall Prevention and Management aid is intended to prompt clinical staff (nurses, physicians, rehabilitation therapists and others) to consider a systematic assessment for determining patients' risk for falling and to recommend interventions.
Restraint Management
Pressure Ulcer Prevention/Management
Methicillin-resistant Staphyloccus aureus (MRSA)
- http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html
- http://www.ihi.org/IHI/Programs/Campaign/MRSAInfection.htm
Handwashing
Rapid Response Teams
Surgical Site Infection Prevention
Congestive Heart Failure
Acute Myocardial Infarction
Pneumonia
Ventilator Associated PN
Central Line Management
Immunizations
Medical Equipment
http://www.ihi.org/IHI/Programs/Campaign/HighAlertMedications.htm
Institute for Healthcare Improvement (IHI), (n.d.). Errors from unreconciled medications
per 100 admissions.
Institute of Medicine (IOM), (2007). Preventing medication errors: Quality chasm
series. P. Aspden, J. Wolcott, J.L. Bootman, & L.R. Cronenwett (Eds.) Washington, DC: National Academy Press. Prepublication copy available at http://www.iom.edu/CMS/3809/22526/35939/35943.aspx
Jones KJ, Skinner AM, Leo C, Cochran GL. Implementing a Program of Patient Safety in
Small Rural Hospitals: Findings and Trends in Medication Error Reporting from 25 Critical Access Hospitals. Nebraska Center for Rural Health Research. (2005).
Tarn, D. M., Heritage, Jl, Paterniti, D.A., Hays, R. D., Kravitz, R. L., Wenger, N. S.
(2006). Physician communication when prescribing new medications. Archives of Internal Medicine, 166(17), 1855-1862
Feldstein, A., Simon, S., Schneider, J., Krall, M., Laferriere, D., Smith, D.H., Sittig, D.
F., Soumeriai, S. B. (2004). How to design computerized alerts to ensure safe prescribing practices. Joint Commission Journal on Quality and Safety, 30(11), 602-613
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_cah_npsgs.htm
Bar Code Medication Administration (BCMA)
Computerized Physician Order Entry (CPOE)
HIT Articles
- Miller, R. H., Sim, I., (2004). Physicians’ Use of Electronic Medical Records: Barriers
and Solutions. Pursuit of Quality, March/April, 2004, 116-124. - Feldstein, A., Simon, S., Schneider, J., Krall, M., Laferriere, D., Smith, D.H., Sittig, D.
F., Soumeriai, S. B. (2004). How to design computerized alerts to ensure safe prescribing practices. Joint Commission Journal on Quality and Safety, 30(11), 602-613
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