John M. Eisenberg Patient Safety Awards. Individual lifetime achievement: Julianne M. Morath,RN, MS

BACKGROUND: This article provides a brief biography of Julianne M. Morath, describes the scope and impact of her patient safety initiatives at Children's Hospitals and Clinics in Minneapolis and St Paul, and includes an interview in which Morath responds to questions about challenges to patient safety and medical accident reduction. BIOGRAPHY IN BRIEF: With a 25-year career spanning the spectrum of health care, Morath has served in leadership positions in health care organizations in Minnesota, Rhode Island, Ohio, and Georgia. LEADERSHIP AT THE FRONT LINE: Morath joined Children's Hospitals and Clinics in 1999 and launched a major patient safety initiative that put Children's on the map. Elements of the initiative included a culture of learning, patient safety action teams, open discussion of medical accidents and error, blameless reporting, and a full accident disclosure policy. AN INTERVIEW WITH JULIE MORATH: As the greatest challenge to leadership ownership of the patient safety initiative, Morath cites the need to confront the myths of the medical system and to develop the awareness of the issues of patient safety. She believes that clinicians on the front lines will be convinced that patient safety isn't "just another fad of the month" when leadership action is disciplined and aligns with what is being espoused. She advises other leaders of health care organizations interested in establishing a culture of safety to start with a personal and passionate belief that harm-free care is possible, to commit to informed action, and to identify and develop champions throughout the organization and medical staff.     

Expanding a performance improvement initiative in critical care from hospital to system

BACKGROUND: Concern about the expense and effects of intensive care prompted the development and implementation of a hospital-based performance improvement initiative in critical care at North Shore University Hospital, Manhasset, New York, a 730-bed acute care teaching hospital. THE HOSPITAL-BASED PERFORMANCE IMPROVEMENT INITIATIVE IN CRITICAL CARE: The initiative was intended to use a uniform set of measurements and guidelines to improve patient care and resource utilization in the intensive care units (ICUs), to establish and implement best practices (regarding admission and discharge criteria, nursing competency, unplanned extubations, and end-of-life care), and to improve performance in the other hospitals in the North Shore-Long Island Jewish Health System. In the medical ICU, the percentage of low-risk (low-acuity) patients was reduced from 42% to 22%. ICU length of stay was reduced from 4.6 days to 4.1 days. IMPLEMENTING THE CRITICAL CARE PROJECT SYSTEMWIDE: A system-level critical care committee was convened in 1996 and charged with replicating the initiative. By and large, system efforts to integrate and implement policies have been successful. The critical care initiative has provided important comparative data and information from which to gauge individual hospital performance. DISCUSSION: Changing the critical care delivered on multiple units at multiple hospitals required sensitivity to existing organizational cultures and leadership styles. Merging organizational cultures is most successful when senior leadership set clear expectations that support the need for change. The process of collecting, trending, and communicating quality data has been instrumental in improving care practices and fostering a culture of safety throughout the health care system.     

John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety

BACKGROUND: In 1998 the Veterans Health Administration (VHA) created the National Center for Patient Safety (NCPS) to lead the effort to reduce adverse events and close calls systemwide. NCPS's aim is to foster a culture of safety in the Department of Veterans Affairs (VA) by developing and providing patient safety programs and delivering standardized tools, methods, and initiatives to the 163 VA facilities. A NOVEL APPROACH: To create a system-oriented approach to patient safety, NCPS looked for models in fields such as aviation, nuclear power, human factors, and safety engineering. Core concepts included a non-punitive approach to patient safety activities that emphasizes systems-based learning, the active seeking out of close calls, which are viewed as opportunities for learning and investigation, and the use of interdisciplinary teams to investigate close calls and adverse events through a root cause analysis (RCA) process. Participation by VA facilities and networks was voluntary. NCPS has always aimed to develop a program that would be applicable both within the VA and beyond. KEY ACTION ITEMS AND RESULTS RELATED TO RCA: NCPS's full patient safety program was tested and implemented throughout the VA system from November 1999 to August 2000. Program components included an RCA system for use by caregivers at the front line, a system for the aggregate review of RCA results, information systems software, alerts and advisories, and cognitive acids. Following program implementation, NCPS saw a 900-fold increase in reporting of close calls of high-priority events, reflecting the level of commitment to the program by VHA leaders and staff.     

The Patient Visits Program: a strategy to highlight patient satisfaction and refocus organizational culture

BACKGROUND: Seeking patient input may improve patients' perceptions of the quality of care and provide managers with helpful information for strategic decision making. In addition, the involvement of senior hospital leadership is critical to successful implementation of quality improvement initiatives and illustrates an organization's commitment to enhancing quality from the top down. IMPLEMENTING THE PVP: Senior management's Patient Visits Program (PVP) at Tufts-New England Medical Center is a structured, ongoing initiative in which senior clinicians are paired with nonclinician administrators. During an initial evaluation period (Aug 1999-Feb 2001), PVP teams visited with patients and their families on a monthly basis to talk to them about their experiences. Patient suggestions were then evaluated and acted on. DISCUSSION: The PVP has been beneficial for patients and for the hospital team members--clinicians and nonclinicians alike--who participated in the patient interviews. The PVP may serve as a mechanism to enhance organizational awareness of the importance of patient satisfaction. The program provides opportunities for immediate service recovery, and faster, broader-reaching responses to quality complaints due to the multispecialty nature of the PVP teams. In addition, based on early available data, the PVP shows promise as an interventional strategy to improve patient satisfaction scores. CONCLUSIONS: A structured, ongoing program such as the PVP is an effective strategy to highlight the value of patient satisfaction, refocus organizational culture, and generate specific suggestions for improving the quality of patient care.     

The AMA clinical quality improvement forum on addressing patient safety

BACKGROUND: More than 200 health care policy makers and researchers, clinicians, quality professionals, and other representatives of health care organizations, government, and academia attended the Division of American Medical Association Clinical Quality Improvement's conference, "Addressing Patient Safety," April 28, 2000, in Chicago--the first national conference to respond to the recent Institute of Medicine (IOM) report, To Err Is Human: Building a Safer Health System. ADDRESSING PATIENT SAFETY--PUBLIC AND PRIVATE PERSPECTIVES: John M. Eisenberg, MD, stated that research on errors is needed to describe the scope and nature of the problem, understand the barriers to and benefits of improvement, and develop and test strategies for improvement. Kenneth W. Kizer, MD, MPH, stated that the National Quality Forum will develop a compendium of best practices and will develop core measures for serious adverse events, and health care organizations and government health programs should act now to make a clear organizational commitment to patient safety, create a nonpunitive health care culture of safety, and implement known safe medication practices. Alan R. Nelson, MD, stated that the IOM report places its emphasis on continuous quality improvement and technology that can be used to mitigate the risks in a complex health system. HOSPITAL AND ACCREDITATION AGENCY ACTIVITIES ON PATIENT SAFETY ISSUES: Donald M. Nielsen, MD, discussed the American Hospital Association's (AHA's) Medication Safety Initiative, which promised to provide its members with successful practices, tools, and resources and to track progress of implementation of the recommended successful practices. Dennis S. O'Leary, MD, stated that when a hospital reports a sentinel event, the hospital is expected to implement improvements to reduce risk and monitor their effectiveness. The National Committee for Quality Assurance is considering changes to its accreditation standards to further address patient safety.     

Developing a systemwide approach to patient safety: the first year

BACKGROUND: Health care organizations face an imperative to ensure that care is provided to patients in the safest manner possible. In 2000 INTEGRIS Health, an Oklahoma City-based health system including ten acute care organizations, developed a patient safety framework that was built on the foundation of a culture of patient safety and began implementation in January 2001. IMPORTANCE OF LEADERSHIP IN PATIENT SAFETY: The first step in establishing a culture of safety was to ensure that leadership and the entire organization understand the rationale for a focus on patient safety. The traditional blaming approach will not prevent human error; staff need to speak freely, to talk about errors that happen and those that almost happen, and to identify where mistakes are likely and where systems allow mistakes to get through. Systems and processes should make it difficult for staff to make mistakes and easy for them to do things correctly. EXPERIENCE TO DATE: Since our efforts began, staff have helped identify multiple accidents waiting to happen. For example, an anesthesiologist, the service chief at one of our large hospitals, prepared a list of safety issues immediately after hearing a presentation to the Medical Executive Committee. Many system flaws have been identified as a result of our discussions; some of the solutions are easy and some much more complex. CHALLENGES: Challenges include keeping patient safety highly visible and demonstrating progress in our implementation, developing effective mechanisms for communicating safety solutions and ensuring that they are implemented in all the facilities, and figuring out how to measure success in a meaningful way.     

Exploring the possibility of a common structural model measuring associations between safety climate factors and safety behaviour in health care and the petroleum sectors

The aim of the present study was to explore the possibility of identifying general safety climate concepts in health care and petroleum sectors, as well as develop and test the possibility of a common cross-industrial structural model. Self-completion questionnaire surveys were administered in two organisations and sectors: (1) a large regional hospital in Norway that offers a wide range of hospital services, and (2) a large petroleum company that produces oil and gas worldwide. In total, 1919 and 1806 questionnaires were returned from the hospital and petroleum organisation, with response rates of 55 percent and 52 percent, respectively. Using a split sample procedure principal factor analysis and confirmatory factor analysis revealed six identical cross-industrial measurement concepts in independent samples—five measures of safety climate and one of safety behaviour. The factors’ psychometric properties were explored with satisfactory internal consistency and concept validity. Thus, a common cross-industrial structural model was developed and tested using structural equation modelling (SEM). SEM revealed that a cross-industrial structural model could be identified among health care workers and offshore workers in the North Sea. The most significant contributing variables in the model testing stemmed from organisational management support for safety and supervisor/manager expectations and actions promoting safety. These variables indirectly enhanced safety behaviour (stop working in dangerous situations) through transitions and teamwork across units, and teamwork within units as well as learning, feedback, and improvement. Two new safety climate instruments were validated as part of the study: (1) Short Safety Climate Survey (SSCS) and (2) Hospital Survey on Patient Safety Culture-short (HSOPSC-short). Based on development of measurements and structural model assessment, this study supports the possibility of a common safety climate structural model across health care and the offshore petroleum industry.     

Preventing home health nursing assistant back and shoulder injuries

BACKGROUND: Franklin County Home Health Agency (St Albans, Vermont) undertook a performance improvement project in 1996 to reduce employee injuries. A review of recent injuries led to the prevention of licensed nursing assistants' (LNAs') back and shoulder injuries as the first priority. Root causes of injuries were agency communication, employee training, patient home environment, nursing assistant body mechanics, and failure to use safety measures. Given that injury causality is complex and multifactorial, a variety of improvement strategies were implemented over the following two to three years. IMPLEMENTATION OF POTENTIAL SOLUTIONS: Short-term (a few months), mid-term (six months), and long-term (one year) potential solutions to the LNA back and shoulder injury problem were charted. Safety and health training was the major focus of the team's short-term plan. Risk management forms were to be used to identify and follow up on hazardous situations. RESULTS: Project plans that were successfully implemented included revision of LNA plans of care, standardization of the return-to-work process after injury, development of guidelines for identifying unsafe patient lifts and transfers, improved follow-up of employee reports of injury-risk situations in patient homes, improved body mechanics screening of new employees, and a stronger injury-prevention training program for current employees. A less successful initiative was aimed at collecting more data about injuries and causal factors. Employee injuries were gradually reduced from 4-10 per quarter to 0-3 per quarter. CONCLUSIONS: Injury prevention requires commitment, persistence, and patience--but not expensive improvements. Multiple interventions increase the chances of success when there are many root causes and lack of evidence regarding the effectiveness of various approaches.     

The safety checklist program: creating a culture of safety in intensive care units

BACKGROUND: In 1999 the VA Ann Arbor Healthcare System began a safety checklist program to help build a culture of safety among nurses, respiratory therapists, and unit maintenance providers in the intensive care units (ICUs). Program objectives were to (a) create the opportunity for each participating staff member to view his or her work and unit environment in a broader safety context; (b) establish clear, concise, and measurable standards that staff would identify and value as important safety factors; (c) develop a data collection methodology that would minimize confirmation bias; and (d) correct safety deficits immediately. DATA MANAGEMENT: Staff measure compliance with safety standards twice daily and record results on a form specifically designed for the project. Data are transferred to a spreadsheet, and graphic presentations are posted in each ICU. Staff periodically adjust both standards and data collection procedures. SUMMARY: Staff can articulate how the program is making the ICU a safer environment. Nursing response to a recent major error reflects the growth that has occurred since the program's inception. Safety checks performed by ICU staff are critical in maintaining a constant level of safety. Although the effect on untoward events was not measured, the potential for incidents, including medication and intravenous errors, nosocomial infections, ventilator complications, and restraint complications may be reduced. The program invests bedside clinicians in writing safety standards, creates a partnership between staff and the clinical risk manager, and provides executive leaders an opportunity to demonstrate support of a culture beyond blame.     

Effectiveness evaluation methodology for safety processes to enhance organisational culture in hazardous installations

Safety performance indicators are widely collected and used in hazardous installations. The IAEA, OECD and other international organisations have developed approaches that strongly promote deployment of safety performance indicators. These indicators focus mainly on operational performance, but some of them also address organisational and safety culture aspects. However, operators of hazardous installations, in particular those with limited resources and time constraints, often find it difficult to collect the large number of different safety performance indicators. Moreover, they also have difficulties with giving a meaning to the numbers and trends recorded, especially to those that should reflect a positive safety culture.

In this light, the aim of this article is to address the need to monitor and assess progress on implementation of a programme to enhance safety and organisational culture. It proposes a specific process-view approach to effectiveness evaluation of organisational and safety culture indicators by means of a multi-level system in which safety processes and staff involvement in defining improvement activities are central. In this way safety becomes fully embedded in staff activities. Key members of personnel become directly involved in identifying and supplying leading indicators relating to their own daily activity and become responsible and accountable for keeping the measurement system alive. Besides use of lagging indicators, particular emphasis is placed on the importance of identifying and selecting leading indicators which can be used to drive safety performance for organisational and safety culture aspects as well.     

Developing a comprehensive electronic adverse event reporting system in an academic health center

BACKGROUND: In September 2000 University of Missouri Health Care (MUHC) conducted an assessment of patient safety activities. At least six separate data systems for reporting adverse events, with multiple conflicting paper reports, were found during this analysis. The disparate nature of these systems and their inability to be linked ensured that few systemic prevention activities were undertaken. In January 2001 an interdisciplinary team was convened with the goal of creating a comprehensive approach to patient safety reporting and resolution. IMPLEMENTATION: A secure, Web-based system, the MUHC Patient Safety Network System (PSN), was created that allows staff, physicians, patients, families, and visitors to report comments, adverse events, and near-miss events from any computer in the hospital and from home, using the Internet. Anonymous reporting is an option for near-miss events. Reports are immediately available to department managers responsible for resolution; managers are alerted to the presence of a report by e-mail. As a result, a pilot study performed in two MUHC intensive care units documented dramatic reductions in resolution time using the PSN. The pilot also demonstrated an increased willingness to report by physicians and respiratory therapists. Training was accomplished in the fall of 2001, and the PSN was successfully implemented throughout the hospital on January 1, 2002. NEXT STEPS: Implementation of the PSN has recently been extended to all ambulatory care settings. An additional component of the PSN that is being built will allow physicians to report complications.     

Failure Analysis of a Natural Gas Pipeline Rupture

From aviation accidents to pipeline explosions, the National Transportation Safety Board is often called to determine probable cause and make safety recommendations, as they did in the aftermath of the 2010 San Bruno pipeline explosion.     

Modelling a macro-ergonomics approach to work systems design: An analysis of organizational context

This study proposes a systematic approach to model and examine the contextual effects of some key organizational factors on the functioning and utility of work practices. Whilst adopting a context-practice-performance conceptual framework, this study examines the relationship between leadership, organizational culture, and quality management practice. A survey was conducted amongst 66 respondents in 35 manufacturing companies in Hong Kong. Three complete mediation models and three partial mediation models were specified and estimated using structural equation modelling (LISREL 8.14). Results show that continuous-learning culture may promote the implementation of process management practices, and that transformational leaders tend to foster cultural changes towards continuous-learning. Results also suggest that the influence of transformational leadership on process management may be largely transmitted through a continuous-learning culture. This indicates that organizational culture may act as an effective mechanism for training overall and for leaders to induce organizational changes. Altogether, these findings suggest that the role of senior executives in promoting a continuous-learning culture could be important in leading a quality improvement programme. More theoretical and empirical work should be undertaken in applying the context-practices-performance framework to help integrate micro- and macro-ergonomics.     

文化传承视域下西夏博物馆文创产品开发策略

西夏博物馆作为承载着诸多西夏历史文化的旅游胜地,对于旅游产业的深入发展有着较高的文化价值。从方法论的角度对西夏博物馆的文创产品设计开发进行分析,将博物馆的文化特色归纳总结,从图形、符号、色彩等3个方面进行重点阐释,丰富博物馆文创产品的开发策略,从而通过文创产品对文物特色进行弘扬与推广,深入挖掘西夏历史文化,带动西夏旅游产业的发展。     

Measuring and improving patients' and families' perceptions of care in a system of pediatric hospitals

BACKGROUND: Shriners Hospitals for Children (SHC) is a network of 22 pediatric specialty hospitals that provide medical care free of charge to children up to 18 years of age and that serve as referral centers for children with complex orthopedic and burn problems. In 1998 the SHC system began using The Picker Institute's Patient and Family Perception of Care inpatient survey throughout its hospitals. SYSTEMWIDE IMPLEMENTATION: A broad-based implementation plan was developed to promote acceptance of the perception of care topic and provide education on performance improvement. In 1999 a work group was formed to prioritize areas for improvement, survey benchmark hospitals, and identify best practices in benchmark hospitals. This work group first focused on the dimensions of Partnership Between Families and Clinicians and Information and Education to the Child. In May 1999 the work group began the task of identifying best practices in these two priority dimensions from the SHC benchmark hospitals. Surveys were submitted to those hospitals, asking what they perceived as being the reasons they scored well in those areas. The results of these surveys were used to identify key practices in these benchmark hospitals that are of significant importance in patient and family perceptions of quality care. NEXT STEPS: The challenge is to facilitate cross-facility interactions to understand and adopt best practices. Focus groups will be conducted to further delineate the dimensions with higher problem scores. The SHC system plans to expand the patient surveys to outpatients, to allow for the evaluation of the full complement of hospital patients.     

The Safety Case Management Committee: expanding the avenues for addressing patient safety

BACKGROUND: The greatest gains in patient safety are likely to result from using a multifaceted framework of safety enhancement initiatives. The Safety Case Management Committee, which has been meeting at the VA Ann Arbor Healthcare System since early 1999, is one such initiative; it is directed at broadening organizational involvement in creating a safer clinical environment. The committee's objective is to address fundamental issues related to patient safety and quality of care. The committee aims to develop thematic approaches to improving major systems triggered by unsafe or risky incidents that demonstrate either iatrogenic harm or risk of harm to patients. COMMITTEE STRUCTURE AND FUNCTIONING: Committee members represent top management, middle management, and front-line employees, but membership is weighted toward those in direct patient care roles. The group also includes a consumer representative. Critical issues are addressed through rigorous case discussion, literature review, and expert consultation. RESULTS: In a 3-year period (Feb 1999 through Dec 2001), 85% of the group's 45 recommendations have been implemented. Topics have included reducing medication errors during emergency procedures, enhancing palliative care services, minimizing the risk of missed x-ray findings, optimizing anticoagulation management, reducing the risk of vascular catheter-related infection, and improving pain management. SUMMARY: The Safety Case Management Committee has successfully addressed actual and potential errors and has implemented strategic safety improvements. The dedicated efforts of highly motivated clinicians who serve on such a committee can augment and enhance risk management advances made through other channels.     

A Web-based program for implementing evidence-based patient safety recommendations

BACKGROUND: In response to increasing national concerns about medical safety, product developers from a health services research and software group recently created a commercial Web-based program to address a wide variety of patient safety issues in the acute care setting. They also wanted to provide a program with credible, referenced, and up-to-date content, not just a technology infrastructure for reporting errors. SAFETY OPTIMIZER: This Web-based program, which has evolved over time, now features seven modules for assessing organizational risk and for implementing strategies to reduce risk. The Literature Module features detailed synopses that are graded and organized into summary statements to provide recommendations for improving patient safety. The Implementation/Tracking Module includes numerous risk-reduction strategies. The Incident Reporting Module enables the collection of data at the point of care on a variety of incidents, using either paper-based or on-line forms. Other modules offer opportunities to assess adherence to JCAHO patient safety standards, forecast the benefits of certain evidence-based guidelines, evaluate staff competency, and obtain information from a variety of key safety Web sites. EXPERIENCE TO DATE: The program is in use at more than 30 health care organization facilities and systems. It is still too early to provide quantitative data on the impact of this program on patient safety. CONCLUSIONS: It is hoped that vendor solutions such as the one described in this article will help organizations develop a practical and effective framework for addressing the wide range of issues in patient safety.     

Approaches to promotion and implementation of action on Radiation Protection for children

The Radiation Protection in Medicine conference, reviewed in this journal supplement, outlined nine strategies to promote radiation protection for patients. The Alliance for Radiation Safety in Pediatric Imaging has focused its work on three of those areas: creating awareness of the need and opportunities for radiation protection for children; developing open-source educational materials for medical professionals and parents on this critical topic for improved patient safety and communication; and lastly, advocating on behalf of children with industry, government and regulatory bodies to improve equipment design and safety features, standardisation of nomenclature and displays of dose reports across vendor platforms that reflect the special considerations of children.     

Emerging research methods and their application to road safety

The study of road safety has seen great strides over the past few decades with advances in analytical methods and research tools that allow researchers to provide insights into the complex interactions of the driver, vehicle, and roadway. Data collection methods range from traditional traffic and roadway sensors to instrumented vehicles and driving simulators, capable of providing detailed data on both the normal driving conditions and the circumstances surrounding a safety critical event. In September 2011, the Third International Conference on Road Safety and Simulation was held in Indianapolis, Indiana, USA, which was hosted by the Purdue University Center for Road Safety and sponsored by the Transportation Research Board and its three committees: ANB20 Safety Data, Analysis and Evaluation, AND30 Simulation and Measurement of Vehicle and Operator Performance, and ABJ95 Visualization in Transportation. The conference brought together two hundred researchers from all over the world demonstrating some of the latest research methods to quantify crash causality and associations, and model road safety. This special issue is a collection of 14 papers that were presented at the conference and then peer-reviewed through this journal. These papers showcase the types of analytical tools needed to examine various crash types, the use of naturalistic and on-road data to validate the use of surrogate measures of safety, and the value of driving simulators to examine high-risk situations.     

Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about

BACKGROUND: The Veterans Administration (VA) identified patient safety as a high-priority issue in 1997 and implemented the Patient Safety Improvement (PSI) initiative throughout its entire health care system. In spring 1998 the External Panel on Patient Safety System Design recommended alternative methods to enhance reporting and thereby improve patient safety. REDESIGNING THE PSI INITIATIVE: The VA began redesigning the PSI initiative in late 1998. The dedicated National Center for Patient Safety (NCPS) was established. Using the panel's recommendations as a jumping-off point, NCPS began to identify known and suspected obstacles to implementation (such as possible punitive consequences and additional workload). NCPS adopted a prioritization scoring method, the Safety Assessment Code (SAC) Matrix, for close calls and adverse events, which requires assessing the event's actual or potential severity and the probability of occurrence. The SAC Matrix specifies actions that must be taken for given scores. Use of the SAC score permits a consistent handling of reports throughout the VA system and a rational selection of cases to be considered. A system for performing a root cause analysis (RCA) was developed to guide caregivers at the frontline. This system includes a computer-aided tool, a flipbook containing a series of six questions, and reporting of the findings back to the reporter. The final step requires that the facility's chief executive officer "concur" or "nonconcur" on each recommended corrective action. The RCA team outlines how the effectiveness of the corrective action will be evaluated to verify that the action has had the intended effect, and it ascertains that there were no unintended negative consequences. IMPLEMENTATION: Based on successful implementation in two pilots, full-scale national rollout to the 173 facilities began in April 2000 and was concluded by the end of August 2000. NCPS supplied 3 days of training for individuals at each facility. The training included didactic components, an introduction to human factors engineering concepts, and small- and large-group simulation exercises. Facility leaders were reminded of the necessity to reinforce the point that assignment to an RCA team was considered an important duty. DISCUSSION: It is essential to design and implement a system that takes into account the concerns of the frontline personnel and is aimed at being a tool for learning and not accountability. The system must have as its primary focus the dissemination of positive actions that reduce or eliminate vulnerabilities that have been identified, not a counting exercise of the number of reports.