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Don't wait. Speak up!

Learn-the-lingo-(2).jpgPeering out onto the tarmac as you settle into your window seat, you feel the stress of everyday life dissolve. This vacation is long overdue. As you patiently wait for the other passengers to board, you hear a sudden, “bang!” from the airplane’s wing just outside your window. A flight attendant walks by and you ask if there is anything wrong with the plane—should we be flying? He calmly reassures you, “I’m sure everything’s fine. Anyhow, we don’t investigate or take action on potential dangers until someone is seriously injured.” Wait. What?
 
It would be unthinkable for an airline to be this unresponsive and indifferent to threats to its passengers’ safety. Likewise, healthcare providers take proactive steps to identify and prevent any possible risk of harm to patients. At EMHS, ensuring the safety of our patients and employees is a top priority.
 
To illuminate and learn from patient safety events and near misses, routine dialog and comprehensive documentation of what did go wrong, or what could have gone wrong, are essential. Reporting is happening now through risk management software like RL6 Solutions, QStatim, and Midas, depending on the EMHS member organization, but we have an opportunity to do more. EMHS set a goal to increase reporting rates by ensuring reporting is: 1) simple and integrated with existing systems; 2) acknowledged; 3) non-punitive; and 4) includes a feedback component to provide learning opportunities and quality improvement.
 
Tim Dentry, EMHS senior vice president and chief operating officer, is leading this system effort to increase reporting and explains, “Every day, mishaps happen in all parts of any organization. The truly great organizations shine a light on, and learn from, those moments. Having the highest standards for patient safety is part of our sustainability for generations to come and key to being a high reliability organization.”
 
EMHS’ culture of patient safety
EMHS uses an Agency for Healthcare Research and Quality assessment tool to understand staff perceptions of the various aspects of patient safety culture. This assessment is another means to improve patient safety and acts as a baseline to identify strengths and areas of improvement in domains such as frequency of events reported, non-punitive response to errors, and feedback and communication about errors. The results of the survey are shared openly with all member organization patient safety teams to learn from, and help close the gap in, patient safety perceptions between frontline and leadership staff.
 
Systemwide work teams are happening now

  • EMHS Harm Identification and Prevention Task Force is comprised of representation from quality and safety, patient experience, and risk management leaders from across system and member organizations. It is charged with establishing a systemwide event reporting structure and process that will lead to risk identification, mitigation, and reduction, to decrease harm for EMHS patients, employees, and visitors. Jeff Parsons, EMHS associate vice president of risk management and chair of the Harm Identification and Prevention Task Force, says, “We are looking to create consistent outputs and unified information about patient safety, with the goals of transparency, accountability, and continuous improvement.”

  • RL Solutions Team has defined workgroups for each module in RL Solutions to define the workflows from a user perspective as well as for manager review of all events.

  • Patient Safety and Clinical Performance Team leads and monitors patient harm events, including near misses. The team is refocusing to share the analysis of trends to identify opportunities for performance improvement at the system, organization, or unit level.

All of this work lives under the umbrella of patient safety and are inter-related with clinical quality, clinical risk management, service excellence, and staff engagement. In the future, we will be doing more to weave them all together. Event reporting takes partnership and a trust at all levels of the organization. Through increased reporting, we are creating a two-way conversation between leadership, front line staff, and the member organizations as a means to learn and improve the culture of patient safety.