Moving from Reaction to Prevention for Patient Safety

Moving from Reaction to Prevention for Patient Safety

It is difficult for leaders to be able to manage, synthesize and act upon all the various patient safety data in a timely manner. Leaders need to manage this information frequently in order to stay on top of their environment and proactively implement strategies to prevent errors from occurring.

Our division has been working to improve their culture of safety, but was still lagging in their ability to manage all the data in a timely manner and therefore, unable to generate timely prevention strategies. We were working in a reactionary, as opposed to prevention mindset. As situations arouse, the division would handle the task at hand. However, little time was spent on preventing further events, if it was not related to a current event. Leaders found it difficult to focus on the prevention of potential errors or events.

Our division implemented a team called the Women’s Common Cause Analysis (CCA) that meets weekly to manage all the information that pertains to Patient Safety to assist in identifying areas of risk and in developing prevention strategies. The Women’s CCA meeting consists of key leaders within the division; the Chairman of OB/GYN, Senior Director Women’s Services, Director, Project Management, Clinical Specialist, Quality, and Risk Management. In addition to the core group, other members of the division are invited to attend on a rotating or ad hoc basis. These representatives include physicians, residents, directors, safety coaches, staff, and members from other departments. The meeting is a safe environment used to help identify opportunities to provide a safer environment for patients and staff. The purpose of this group includes: (1) reviewing data on safety from various sources to include; occurrence reports, mislabeled specimens, red rule violations, targeted audits and anecdotal information, (2) addressing or following up any immediate concerns, (3) identifying trends or concerns within the division, and (4) developing a safety message or “Safety Huddle” which is shared with all staff for the week. The message is specific to concerns or risks identified within the division or hospital. The Safety Huddle is delivered by the department director and is used as an opportunity to dialogue with the staff about the message and solicit staff safety concerns or “good catches”. In addition to sharing the message for the week, a specific topic is addressed for feedback, and is sent back to the team for consideration.

The CCA team has met every week for over 18 weeks. The safety message has been generated each week with over 85% of the division’s staff hearing the message. The staff reports they feel better informed about issues related to safety. In addition, the issues identified are not only being immediately addressed, but practice changes are occurring. This presented issues regarding communication with handoffs. The Women’s CCA team has helped to move the emphasis on creating a transparent culture in sharing critical information as it relates to patient safety.