Information de reference pour ce titreAccession Number: | 00019514-200507000-00002.
|
Author: | Odwazny, Richard MBA; Hasler, Scott MD; Abrams, Richard MD; McNutt, Robert MD
|
Institution: | Patient Safety Committee, Department of Medicine, Rush University Medical Center, Chicago, Ill.
|
Title: | |
Source: | Quality Management in Health Care. 14(3):132-143, July/September 2005.
|
Abstract: | Objective: To describe an approach and experience with fostering a culture of patient safety.
Methods: (1) Organizational Change-The Department of Medicine established a patient safety committee (PSC) and charged it with reviewing adverse events. (2) Cultural Change-PSC sponsors and participants work to promote a culture of collaboration, study, learning, and prevention versus a culture of blame. (3) Collaboration-The PSC includes chief residents and members from medical informatics, nursing, pharmacy, quality assurance, risk management, and utilization management. (4) Evolution-The duties of the PSC progressed from merely learning from adverse event reports to implementing patient safety and quality improvement projects. (5) Standardization-The PSC uses standard definitions and procedures when reviewing cases of adverse events, and when conducting patient safety and quality improvement projects.
Results: (1) Developed an online adverse event reporting system, shortening the average report collection time by 2 days and increasing the number of adverse events reported. (2) Established a model for change using (a) safety rounds with residents, (b) e-mail safety alerts, and, in some cases, (c) decision alerts using electronic order entry. These changes in culture and capability led to improvements in care and improved financial results.
Conclusions: Senior management support of a culture of learning and prevention and an organizational structure that promotes collaboration has provided an environment in which patient safety initiatives can flourish by providing not only safer and higher quality patient care but also a positive financial return on investment.
(C)2005Lippincott Williams & Wilkins, Inc.
|
Author Keywords: | culture; guidelines; outcomes; safety; standards.
|
References: | 1. Smith W. Evidence for the effectiveness of techniques to change physician behavior. Chest. 2000;118:8S-17S.
2. Mcnutt R, Abrams R, Hasler S, et al, for the Patient Safety Committee. Determining medical error: three case reports. Eff Clin Pract. 2002;5:23-28.
3. Caplan RA, Posner K, Cheney FW. Effect of outcome on physician judgments of appropriateness of care. JAMA. 1991;265:1057-1060.
4. McNutt R, Odwazny M. Analyzing and minimizing error: a conversation with Robert A. McNutt, MD. Qual Manage Health Care. 2001;10(1):85-88.
5. McNutt R, Odwazny M. Continuing the journey to patient safety. Qual Manage Health Care. 2004;13(1):88-92.
6. McNutt R, Odwazny M. The theory of constraints and medical error: a conversation with Robert A. McNutt. Qual Manage Health Care. 2004;13(3):183-187.
7. Utiger F, Hoigne R, D'Andrea Jaeger M, et al. Hyperkalemia with potassium-sparing and potassium-losing diuretics. Results from the Comprehensive Hospital Drug Monitoring, Bern. Schweiz Med Worchensher. 1990;120:1933-1936.
8. Gearhart J, Duncan J, Replogle W, Forbes R, Walley E. Efficacy of sliding-scale insulin therapy: a comparison with prospective regimens. Fam Pract Res J. 1994;14(4):313-322.
9. Baldwin D, Villanueva G, McNutt R, Bhatnagar S. Eliminating inpatient sliding scale insulin: a re-education project with medical house staff. Diabetes Care. 2005;28:1008-1011.
10. Yadav D, Agarwal N, Pitchumoni C. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002;97(6):1309-1318.
|
Language: | English.
|
Document Type: | Article.
|
Journal Subset: | Behavioral & Social Sciences.
|
ISSN: | 1063-8628
|
NLM Journal Code: | bv0, 9306156
|
Annotation(s) | |