Patient Safety / Risk Management in 2016

[texas76177]

Hello Folks

I am tasked with doing a research paper on Patient Safety and Risk Management in hospitals, for a project.

Recent best selling books have come out, The Checklist Manisfesto and Confessions of a Surgeon, both of which have put patient safety somewhat to the front of the public's mind.

With that said, I would like to ask the following questions:

1. Assuming past efforts have had marginal effectiveness, What indeed needs to be done to improve Patient Safety ?

2. What organization is best suited to put on training, etc ? JCAHO ? Corporate HQ (HCA, Tenet, etc) ?

3. Would aviation-style Crew Resource Management (CRM) training assist with improving Patient Safety

Note that I am not talking about "blame avoidance" , CRM is more of a team-work based approach

4. Does the concept of "Just Culture" exist at your hospital ? If not, why not ?

5. How do we get "buy-in" for the medical professional ? Link Patient Safety education/training programs to CME credits ? Insurance Discounts ?

6. How do we get "buy-in" for the Hospital Administrator / CEO ?

7. Big brand-name hospital may indeed have a training program for Patient Safety, the Mayo and Cleveland Clinics. However, what is the local, small-town hospital doing to educate staff and employees ? Topeka, Kansas General Hospital ? Could those smaller hospitals see some improvements in their Patient Safety education and training efforts ?

If "it was up to you" as a medical professional, what would you do to improve Patient Safety ?

With the rapid growth of the medical field, and more and more hospitals springing up, combined with an aging population (and thus increased "client" numbers of patients), this topic [Patient Safety] is not going to just go away.

Thank you !

[amoLucia]

Sounds like homework.

[nutella, MSN, RN]

For all of your questions you can find plenty of peer reviewed academic articles in a library. Let's say you pick initially 3 articles that address each of your question you should get at least a baseline idea and might get further ideas.

One of my favorite web pages for inspiration and information regarding patient safety is :

Quality Improvement | Agency for Healthcare Research & Quality

Personally, I think patient safety is a multi facet approach that often includes a culture change.

CRM methods have some application (eg SBAR, OR check lists) to address the culprit of errors - human error and communication.

Buy in is different for different groups (nurse, admins, physicians...).

If your homework is to develop a specific project my advice would be to first find an area of improvement that also exists in smaller hospitals - for example go to

Medicare Hospital Compare Overview

and look for a hospital the size you are targeting and review data as quality also influences payment.

You will get an idea of what is relevant.

Pick a problem and develop a plan to increase safety that includes training.

Plan-Do-Study-Act (PDSA) Worksheet

gives you some more ideas and talks also about PDSA cycle. By the way - they also offer for free classes for students...

Projects are usually easier to manage when you can narrow them down. If you make it too broad it will be too much or you will get tangled up.

Nowadays it is not just about pat safety and quality but also about payments. The money argument does float a lot with management but not with the bedside nurse...Popular topics are probably fall safety, patient hand off, risk management OR, bar code assisted tasks (medication/transfusion/blood draws)..

Good luck!

[texas76177]

Thank you for the info ! Yes, homework....

[amoLucia]

Just curious - where did you get those questions you're asking here? Did you develop them yourself or were they given to you or pulled from another source?