RISK MANAGEMENT

Recognising Risk and Improving Patient Safety - Mildred's Story



Recognising Risk and Improving Patient Safety - Mildred's Story

Introduction

In 2009, The Institute of Medicine reported that there was a serious patient safety problem in the United States. This alarming profusion of health care errors has received attention from federal and state lawmakers, health care organizations, and individual health care providers alike. Safety experts from many professions also began to take a look at this issue. A great deal of research then began to investigate why such errors occur, and what can be done in the health care industry to begin to combat this problem. There have been numerous studies published, documenting the effectiveness of system-based changes related to patient safety, summarized in this article (Conklin, 2007, pp. 17).

In addition, Congress has gotten involved by passing legislation in 2003 and 2004 that is intended to increase the reporting of errors in order that safety issues will be identified, and patient safe organizations will be created. Safety culture is becoming increasingly recognized as a critical strategy and also necessary before identifying where deficits occur related to patient safety issues. Culture is defined in many ways, and many tools exist in assessing a unit or organization for the safety culture that exists. Patient safety climate surveys vary considerably.

One hospital has embraced the challenge to reduce error and promote a culture that is focused on safety by implementing a Patient Safety Program. This hospital is a 475 bed, not for profit, academic pediatric hospital. The purpose of the Patient Safety Program is to identify, evaluate, reduce, respond and prevent harm related to medical care in all areas of the organization. Harm may be the result of errors of commission or errors of omission. In 2006, this organization embarked upon a priority initiative. Safety would be the #1 initiative hospital wide. The goal was to reduce serious safety events by 80% by June 30, 2008 by improving the safety culture. The safety program is based upon work begun by Senatra, a six-hospital system in Norfolk, Virginia. The basic approach to safety is the STAR method, which means, “stop, think, act, and review” (Kenney, 2008). Training began of all staff across the entire hospital. The training is called aSSERT training, which is an acronym for a Serious Safety Event Reduction Team. A timeline was set for all departments and disciplines that cared for patients. This included physicians, nurses, respiratory therapists, occupational therapists, physical therapists, speech therapists, audiologists, pharmacists, radiology technicians, child life specialists, and social workers (Clancy, 2005, pp. 193).

Importance of risk management

Healthcare organizations are today, under great challenges posed by steadily increasing costs due to increasing care activity and the increasing complexity and specialization of the processes and techniques used. This situation has also a significant increase in the risks associated with health care processes. Improving patient safety is a strategic objective shared by the entire industry. AENOR, aware of this reality, and participant in the plans and programs of quality improvement that have ...