Thanks to all who will keep the conversation going in my absence.
Make way for the guest bloggers!
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We are convening a team to begin evaluation (called a Value Stream Mapping) of our Safety Incident Detection and Response System. This means we are looking at our error detection system and our system response. We will have community members on this team and we plan to seek assistance from experts in the safety industry such as hazardous materials experts who work with local refineries and others.All staff are welcome at the opening session on Monday July 26 at 11:00 AM to 1:00 PM at CCRMC Building One Conference Room One.
• Learn: Analyze the information- look for patterns/insightsImage source: IDEO.com
• Look: Observe, discover what people do rather than what they say they do
• Ask: Get input of others
• Try: Simulate and test to empathize with users and evaluate your design proposal
1. We need to move from looking at errors as individual failures to realizing they are caused by system failures;To further complicate matters, systems for identifying and learning from patient safety events need to be improved. Safety reporting systems are often laborious and cumbersome. Health care providers express fear that findings may be used against them in court or harm their professional reputations. Many factors, such as concerns about sharing confidential data across facilities or State lines, limit the ability to aggregate data in sufficient numbers to rapidly identify important risks and hazards in the delivery of patient care. More work is also needed to develop measures that capture the underlying processes and conditions that lead to adverse events and the practices that are most effective in mitigating them.(AHRQ, NHQR 2009)
2. We must move from a punitive environment to a just culture;
3. We move from secrecy to transparency;
4. Care changes from being provider (doctors) centered to being patient-centered;
5. We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, interprofessional teamwork;
6. Accountability is universal and reciprocal, not top-down.Leape L.Errors in medicine. Clinica Chimica Acta,6 June 2009,404(1)2-5