A comprehensive program to promote adoption of a “fair and just” culture improves employee perceptions of how a health system responds to errors.
A two-hospital system implemented an intravenous infusion safety initiative that has helped avoid many infusion-related errors, leading to significant cost savings and high levels of nurse satisfaction.
A pediatric academic medical center adopted a standardized ordering and administration process for total parenteral nutrition, leading to a significant reduction in errors and other improvements.
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 University of Michigan Medical Center uses patient safety rounds to help establish a culture of safety within the organization; during these rounds, hospital management and frontline staff work together to identify hazards and take actions to reduce or eliminate them.
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.
A hospital association forged consensus on statewide standards for use of color-coded wristbands and provided implementation support to hospitals, leading to widespread adoption of the standards.