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Empowering Culture Change and Safety on the Journey to Zero Harm With Huddle Cards
Michael T Finch1, Brandon Mason1, Nicole Volek1
1Veterans Affairs Central Texas Veterans Health Care System, Temple.
Background:
Safety event reporting plays an important role in improving patient safety. The US Department of Veterans Affairs has focused on minimizing or eliminating harm to patients.
Observations:
The patient safety (PS) and high reliability organization (HRO) teams at the Central Texas Veterans Health Care System (CTVHCS) developed an education model that integrates the Joint Patient Safety Reporting System (JPSR) into huddles. JPSR Huddle Cards provide frontline staff and management with guidance on the purpose of the JPSR, the difference between an adverse event and a near miss, what root causes are, the lifespan of a JPSR, how to celebrate reporting, and key fact checks. Six cards were presented to staff (1 per week) during morning safety huddles to support the CTVHCS journey to high reliability. Participants completed a survey on safety before and after receiving the cards.
Conclusions:
Posttest scores were consistently higher than pretest scores, with an average increase of around 2 standard deviations across all questions.
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