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The following policies pertaining to Leadership, Management and Staff were approved by MHA's Patient Safety Committee on May 2, 2001:
For Leaders
Patient safety is a foremost responsibility of the leaders within each health care organization. Health care executives and board of trustees must pronounce patient safety a high priority, incorporate into their organizational infrastructure, and allocate resources required to initiate and sustain safety programs. Leaders will be accountable to initiate, lead, and oversee patient safety programs. They will champion a 'beyond blame' culture through demonstration and effective communication throughout all levels of their organization. Leaders will establish appropriate policies and procedures that reflect a full disclosure policy. It is recommended that members consider the language from the National Patient Safety Foundation Statement of Principle when developing policies and procedures.
For Managers
Managers will take an active role in implementing and disseminating 'best practices.' Clinical leaders will provide a safe environment for staff to work in addition to providing a safe environment for patients and their families to receive care, they will encourage staff and patients/family input on ways to improve safety. They will encourage staff and patient/family input on ways to improve safety. Managers will be supportive, in every way possible, to their employees and consumers after a medical accident or 'near accident' occurs and implement processes to prevent replication of the same situation.
For Staff
Health care staff, including anyone that provides patient care in a facility such as employees, medical staff, and contracted staff, will actively take a role in creating a safe environment for themselves, peers, and patients and families through meeting organizational and professional standards, following 'best practices,'proactively intercepting unsafe conditions, and voluntarily reporting accidents and near misses according to policy. Staff will take the responsibility to keep informed of recommended successful practices and safety alerts. They will welcome input from, and involve peers and patients and their families to provide the safest possible care.
Tools
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Tools listed on left are appropriate for:
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Leadership
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Management
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Staff
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"Redefining the Culture of Patient Safety:" This brochure was created by the Minnesota Alliance for Patient Safety (MAPS) to address the cultural barriers to patient safety by redefining the language around patient safety, and demonstrating that medical accidents are a result of system failures rather than individuals. To order, go to MHA's online store, or download the order form: [DOC].
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"Hospital Executives and Their Role in Patient Safety:" this self-assessment tool for executives serves as a guide to trigger action and improve patient safety processes. The tool can be ordered through the American Hospital Association, (800) 242-2626, item # 166924. $10 for members/$20 for non-AHA members.
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"Beyond Blame": This video features Don Berwick, president and CEO, Institute for Health Care Improvement. The video calls for leadership to create a culture change in their organization necessary to make patient safety a priority. To order, contact Bridge Medical at (858) 350-0100.
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Medical Device Use-Safety: Incorporating Human Factors Engineering into Risk Management." This online document was developed by the FDA to describe how hazards relating to medical devices should be addressed during device development, use, and procurement.
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The Risk Management Foundation of the Harvard Medical Institutions: The Risk Management Foundation's mission is to design models and systems by which delivery of patient care is made safer. This site has frequently-asked questions on adverse events and recommended responses to an event:
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National Guideline Clearinghouse: These are online clinical practice guidelines sponsored by the Agency for Healthcare Research and Quality in partnership with the American Medical Association and the American Association of Health Plans.
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Institute for Clinical Systems Improvement: This Web site contains clinical guidelines that are developed by the national guideline clearinghouse and are expanded upon by ICSI to make them practical for the clinician.
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Adverse Drug Event trigger tool from the Institute for Healthcare Improvement: This is a tool that makes one think about harm caused to patients rather than error. There are 24 triggers, which are identified in a retroactive chart review, which may indicate error.
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Minnesota Alliance for Patient Safety's core patient safety resources and reading list.
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Links to reliable patient safety organizations
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Strategies for Leadership: This quality of care video is aimed at leadership for improving patient safety. There are key questions in a workbook that trigger process improvement. $10 for AHA members, $20 for non-AHA members. For more information, contact the American Hospital Association at (800) 242-2626.
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MHA policy on statements of belief and responsibility of reporting systems: [PDF] MHA's Patient Safety Committee approved these statements on May 2, 2001. The statements include support for standardization, capturing near- misses, creating environments to encourage reporting, providing useful information to professionals and consumers, and open communication following an event.
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Patient Safety Manifesto: [PDF]. This tool that originated from three years of work during the Harvard Executive Session on patient safety, and was modified by the Minnesota Alliance for Patient Safety (MAPS) Best Practice Subcommittee to create an education tool to implement throughout all levels of the organization including leadership, management, and all other hospital staff. This manifesto is a public declaration that patient safety is a high priority for health care organizations.
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Allina Health System 10 Actions to Impact Cultural Assumptions around Patient Safety lists the 10 most important actions to be taken by each Allina hospital site to demonstrate measurable improvement in the culture around patient safety. Contact Tania Daniels, MHA, for more information.
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Institute of Medicine Reports:
1) IOM I, released November of 1999: "To Err is Human" This report was a compendium of patient safety research and literature. The report objectified the number of patient injuries, deaths, and costs related to medical errors. The report was a call to action to address patient safety.
2) IOM II, released March of 2001: "Crossing the Quality Chasm: A New Health System for the 21st Century." This report is a call to action to overhaul the overall quality of the health care system.
3) National Health Care Quality Report, released April 2000: "Envisioning the National Health Care Quality Report." This report describes both the short-term and long-term plans for a national quality report, which will be annually beginning in 2003. There are four components of health care quality to be measured: Effectiveness, Patient Safety, Patient-Centered Care, and Timeliness.
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"Reducing Medical Errors and Improving Patient Safety: Success from Front Lines of Medicine:" Accelerating Change Today, and "Reducing Adverse Drug Events, Lessons from a Breakthrough Series Collaborative."
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Institute for Safe Medicine Practice (ISMP): This site issues medication safety alerts.
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JCAHO Sentinel Event Alerts: http://www.jcaho.org/general+public/patient+safety/index.htm.
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Reporting mechanisms: There are multiple reporting systems on the national level such as FDA, JCAHO, CDC, MedMarx, ECRI. There is a patient safety task force commissioned out of the DHHS to integrate existing reporting systems at the national level and to work closely with the state level reporting systems such as MHA's Patient Safety Registry.
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Consumer tips - This patient fact sheet provides 20 tips to help prevent medical errors and the active role that consumers can take.
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Recommended facility specific safety tool kit enclosures: 1) Facility policy on reporting; 2) Support available after an error or a near miss; 3) Core safety behaviors/performance review; 4) Facility specific safety initiatives; 5) Process to recommend an improved safety process/environment.
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