Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "good catch"...

Area of Science:

• Healthcare Quality Improvement
• Patient Safety Research
• Surgical Suite Operations

Background:

• Hospitals have invested in quality and patient safety since 1999.
• Initiatives include leadership involvement, safety culture, education, committees, and reporting systems.
• A specific patient safety reporting process was developed at The Johns Hopkins Hospital's Weinberg Surgical Suite.

Purpose of the Study:

• To maximize the usefulness of patient safety reports.
• To ensure the long-term sustainability of quality improvements.
• To detail a novel patient safety reporting framework.

Main Methods:

• A six-phase framework (Identify, report, analyze, mitigate, reward, follow up) was implemented.
• Utilized UHC's Patient Safety Net (PSN).
• Employed a multidisciplinary team for report review, hazard mitigation, provider education, and recognition via 'Good Catch' awards.

Main Results:

• 29 patient safety hazards were identified and mitigated since 2008.
• 86% of associated quality improvements have been sustained.
• Detailed examples include heparin concentration errors and rapid infusion device issues.

Conclusions:

• A multidisciplinary team approach to analyzing and mitigating hazards is effective.
• Positive recognition through 'Good Catch' awards, practitioner education, and follow-up are key components.
• This process enhances the sustainability of quality improvements in patient safety.