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Closing the Loop on Patient Safety:
Quality Forum 2013
•Naomi Erickson, BSN, MHS•Maureen MacKinlay, MSW
Disclosure
Naomi Erickson & Maureen MacKinlay both work for Interior Health
Neither Naomi nor Maureen have any relevant financial or non-financial relationship to disclose
Traditional thinking about patient safety
Well trained conscientious employees didn’t make errors
Error = incompetence & stigma Punishment = more careful employees
This kind of toxic, blaming culture resulted in reduced compliance with reporting
Learning opportunities were limited (Emanual, et al, 2005)
Contemporary Thinking 1990’s – shift to systems thinking Analysis to better understand the
elements that influence safety Sharing information More information shared = better learning
industry wide Patient Safety Learning System (PSLS)
PSLS Offers process for reporting incidents Has ability to produce reports, showing
trends PSLS is a tool to report safety events but
on its own, it fails to feedback to the reporter and others systems improvements
The result of not sharing our learning can be repeated, preventable errors
Why is this an issue? Staff feedback is that they are not aware
of actions resulting from their report Staff are not aware of all quality
improvement initiatives Missed opportunity to look for alternative
answers to complex problems Missed opportunity to share learning Missed opportunity to raise awareness of
safety
Options for Closing the Loop
Obligation of leaders to share learning with patients, staff and others
• Staff meetings• Patient Safety Walkabouts• Newsletters• Safety Huddles• Posters
Posters highlight: What happened Significance of the problem Multi-factors that contributed to
incident• Environmental• Systems• Human resources
Changes made to mitigate future occurrences of the incident
Applicability of learning
Evaluation of Feedback Method Programs at two tertiary psychiatric sites
were surveyed to determine:• Were the posters a way an effective
way to share learning?• Did it change the employee’s
perception of the organization’s commitment to safety?
Results of survey showed posters were an effective way to share learning.
Transformed Organization Lessons shared with other mental health
programs (knowledge translation) Highlighting learning from one experience
is validating to staff who have taken time to report
Discussion about patient safety incidents involves staff in problem solving
Reporting in the PSLS is reinforced Improved Culture of Safety and Learning
References Emanual, L., Berwick, D., Conway, J. et al (2008).
What exactly is patient safety? In Henriksen, K., Battles, J, Keyes, M. et al, Eds., Advances in patient safety: new directions and alternative approaches (Vol. 1 Assessment). Rockville (MD): Agency for Health care Research and Quality. Advances in Patient Safety. 2008 Aug. Available on line at www.ahrq.gov/advances2/.
IMIT Engagement 16
Questions