Monthly patient safety conferences that allow clinicians and all levels of staff to openly discuss adverse events improved staff perceptions of the organization's safety culture and increased the reporting of such events.
A medical center adopted a comprehensive process that includes proactive reporting and investigation of potential errors, full disclosure and apology when errors occur, and fair remedy and compensation, leading to similar or lower than average claims costs.
Unit-based teams of physicians, nurses, and quality leaders develop and implement unit-specific initiatives designed to improve quality and safety, leading to reductions in infections and pressure ulcers, increased adherence to medication reconciliation standards, more reporting of errors and near-misses, higher patient satisfaction, and better overall nurse/physician communication and teamwork.
A multifaceted process for full disclosure of medical errors leads to a significant reduction in claims and claim costs for a health system.
A comprehensive program to promote adoption of a “fair and just” culture improves employee perceptions of how a health system responds to errors.
Safety mentors at Christiana Care Health System help staff implement best-practice safety behaviors and reporting of errors and near misses, leading to a reduction in serious adverse events and increased identification and/or reporting of near misses.
The Healthcare Alliance Safety Partnership was a 3-year pilot project involving a board of nursing and three hospital systems in developing a voluntary, nonpunitive system for reporting, investigating, and analyzing nursing errors.
A children's hospital annually reviews all findings from root cause analysis to identify and address common themes and vulnerabilities, leading to a number of institutionwide changes that have improved patient safety and to better communication about safety issues with organizational leaders.
A hospital outpatient clinic's confidential, voluntary error reporting system, which focuses on identifying faulty systems instead of individual mistakes, has substantially increased error reports and has been associated with a reduction in liability claims.
A hospital's ambulatory pediatrics department developed a voluntary, anonymous, and nonpunitive medical error reporting system that includes a quick response team to review reports and enact interventions to prevent recurrences, leading to a significant increase in error reporting.