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    Creating a Culture of

    Patient SafetyWVU Department of Family Medicine

    RCB HSC- Eastern DivisionKonrad C. Nau, MD

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    We work in a complex environment

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    We know that error happens

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    We know that patient safety is the

    bedrock of quality care

    Institute of Medicine: Quality Care

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    IOM elements of Quality

    Safe: avoiding injuries to patients from the care that is intended to helpthem

    Timely: reducing waits and sometimes harmful delays for both thosewho receive and those who give care

    Effective: providing services based on scientific knowledge to all who

    could benefit and refraining from providing services to those not likely tobenefit (avoiding underuse and overuse)

    Efficient: avoiding waste, in particular waste of equipment, supplies,ideas, and energy

    Equitable: providing care that does not vary in quality because ofpersonal characteristics such as gender, ethnicity, geographic location,

    and socioeconomic status Patient-Centered: providing care that is respectful of and responsive to

    individual patient preferences, needs, and values and ensuring thatpatient values guide all clinical decisions

    STEEEP Framew

    orkoutlined by the Institute of Medicine (IOM)

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    We preach quality but can we say

    we have a true culture of safety

    Culture

    The way we do things around here

    Safety

    Avoiding injuries from care intended to help

    patients

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    Can everyone in our clinic name

    five ways to improve patient

    safety ?

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    AHRQ

    Five Steps to Safer Health Care 1. Ask questions if you have

    doubts or concerns.

    2. Keep and bring a list of ALLthe medicines you take.

    3. Get the results of any test orprocedure.

    4. Talk to your doctor aboutwhich hospital is best for your

    health needs.. 5. Make sure you understand

    what will happen if you needsurgery.

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    Delivering on our Promise of

    Quality Medical Care

    Patient Safety

    Quality Care

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    Patient Safety &

    Quality Medical Care

    Two fundamental questions guide us, as a world-classacademic family medicine center, and in this order:

    1.How can we help the patient?

    2.In doing so, what can we learn?

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    Patient Safety Campaign

    WVU Dept Family Medicine-East Div

    1.Patient Safety Kickoff

    2.System of Reporting and Analyzing Error

    3.Regular Patient Safety Grand Rounds

    4.Create a Culture of Safety

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    Patient Safety Kickoff

    Entire office assembled off-site for lunch meeting

    January 2005

    Present : Epidemiology of Medical Error

    Present : Creating a Culture of Patient Safety

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    System to Report and Analyze Error

    Electronic Occurrence Reporting System

    Quantros/Dr Quality/ORM

    Web based

    We encourage ALL staff to file reports online

    Patient injury

    Adverse drug reactions

    Near-misses

    Non-putative, can be filed anonymously

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    https://qxpert.quantros.com/orm/jsp

    /JeffersonLogin.jsp

    Click here to report an occurrence (a.k.a. variance or incident) anonymously. You do

    not need a User ID or Password to do this. Please assist us in creating a safer

    healthcare environment for the customers we serve

    http://check%28%29/

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    Resident Physicians

    Reporting and Analyzing Error

    All residents are REQUIRED to self report theirown medical errors.

    Electronic format is confidential and Peer

    Review protected. Encourages reflection and honesty expected in

    physicians

    Non-putative focus on systems-based analysis

    Will formulate basis of Patient Safety GrandRounds topics

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    Patient Safety Grand Rounds

    Bimonthly residents, faculty, students, invited clinic

    staff

    Based on residents self reported medical error or near

    miss

    Clinical case presented

    Systems-based analysis of the error

    Present patient safety literature that supports

    recommendations Case Report and analysis is written up and reviewed with

    Chair prior to required submission to AHRQ M&M

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    Create a Culture of Patient Safety

    Enhance clinic library with Patient Safety materials

    Journal of Patient Safety

    Patient Safety & Quality Healthcare Journal

    Seminal textbooks

    Crossing the Quality Chasm

    To Err is Human

    Enhance clinic technology for Patient Safety

    Clinic wide Lexicomp/Drug Interaction software on all

    computers and handhelds Redesign Clinic Web Page

    Medication Charts

    Office Visit preparation/safety tips

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    Create a Culture of Patient Safety

    AHRQ Patient Safety Culture Survey

    http://www.ahrq.gov/qual/hospculture/

    Outpatient format available in PDF or Word

    Results display template on PowerPoint

    Involve entire clinic in patient safety culturesurvey

    Patient focus groups to inform clinic aboutpatient stakeholder perspectives

    Clinic leadership makes Patient Safety Rounds

    http://www.ahrq.gov/qual/hospculture/http://www.ahrq.gov/qual/hospculture/

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    Patient Safety Culture Survey

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    25

    30

    15

    70

    50

    80

    20

    15

    5 25

    5

    60

    Overall Perceptions of Safety

    R Indicates reversed-worded items.

    NOTE: The item letter and number in parentheses indicate the items survey location.

    Survey Items % Strongly Disagree/ % Neither % Strongly Agree/Disagree Agree

    1. Patient safety is never sacrificed to get more

    work done. (A15)

    2. Our procedures and systems are good at

    preventing errors from happening. (A18)

    R3. It is just by chance that more serious

    mistakes dont happen around here. (A10)

    R4. We have patient safety problems in this

    unit. (A17)

    Page

    Sample culture Survey result slide:

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    Quality Primary Care for the

    21st Century

    Safe Patient CareConsistent Best Practices

    Great Patient Service

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    Ambulatory Patient Safety Culture

    Create a Culture of Safety

    Culture = the way we do

    things around here

    Culture of SafetyRequirements

    Visualize a safe system

    Non-punitive environment

    Leadership support

    Patient Safety

    Quality Care

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    Ambulatory Patient Safety

    Capture errors that occur

    Analyze errors

    Follow-up on analysis

    Safety projects will emerge

    Medication

    EMR

    Communications

    Team work

    Test results

    Pt education about safety

    Patient Safety

    Quality Care

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    We need creativity

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    We need enthusiasm

    We need you.


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