HACs
What does HAC stand for?
Hospital Acquired Conditions. Can also appear as HAI (hospital acquired infection). They are described as preventable harm
What is read back and verify? Also called closed-loop communication.
Strategy where staff repeat back critical information to confirm accuracy.
Repeat back to confirm understanding
What is the role of frontline staff in building and maintaining a strong safety culture?
Identifying hazards, reporting safety concerns and incidents, and engaging in continuous improvement efforts. Also adopting and applying error prevention strategies
What is a safety huddle?
A brief meeting where staff discuss potential safety concerns for a patient, unit, etc. Identify issues or risks, spread awareness, and engage the team for problem solving. Also ensures all stakeholders are informed.
What is a HAC committee member? What is their role?
Attend HAC team. Report back to your unit or department any information shared during the meeting. Be engaged in discussion and bring forward ideas and feedback.
What is our overall HAC prevention goal? What are we striving for?
Zero Harm!
Hero for Zero
What is SBAR?
A structured communication method to enhance efficiency and clarity of information sharing.
Situation, Background, Assessment, and Recommendation
What is the role of psychological safety in reporting errors?
It encourages staff to report mistakes/errors without fear of punishment. The only way leadership can make meaningful change is with reporting and coordination of opportunities from front facing staff
What is a way to describe how staff complete a task, compared to how a manager/supervisor designed the task to be carried out?
Proactive safety tools are pivotal in getting feedback from frontline staff on what is actually going on, instead of how leadership perceives it.
What is a HAC champion? What is their role?
Responsible for completing audits and reporting back progress of project work in their areas. HAC representative leaders for their respective areas
What is SPS' primary means of HAC prevention? How do we track them at JDCH? Who completes these?
Bundle audits
Tracked via Redcap
HAC champions
What is a time-out?
Final verification process, usually before surgery to confirm the right patient, procedure, and site.
What is high reliability in healthcare?
A consistent approach to preventing errors in high-risk environments. Relies on reliable processes and reliable staff (who employ error prevention strategies and mindset)
What is a culture of safety survey?
Tool used to measure staff perceptions of patient safety and safety culture. Leaders use feedback to guide their efforts in promoting safety and safety culture teachings.
What is a HAC lead? What is their role?
Supervise and manage SPS data entry, analyze trends, oversee projects for HAC prevention. Manage monthly meeting, report out project progress, and ensure bundles are completed reliably.
Name as many JDCH HAC groups as you can. (We currently have 9 teams, covering 10 HACs)
Adverse Drug Events/Peripheral IV Infiltrates and Extravasations
Central Line Associated Bloodstream Infections
Falls
Pressure Injuries
Surgical Site Infections
Unplanned Extubations
Employee/Staff Safety
Safety Disparities
Ambulatory Safety
What should you do when you notice an error has been made?
Follow necessary steps to stabilize the patient, then submit an incident report. Incident reports enable the hospital to build more safety mechanisms into our processes to increase safety. We follow Just Culture methodology, so blame is not assigned to the individual (non-punitive)
What is a Just Culture?
An event review methodology which balances accountability with learning from mistakes. The primary goal in reviewing incidents is to learn and grow as an organization. Individuals are not punished for mistakes.
What is the difference between reactive and proactive safety?
Reactive safety responds to harm after it occurs, while proactive safety prevents harm before it happens. Proactive safety involves learning from everyday work as it is done, and identifying and mitigating challenges. Reactive work relies on learning from a safety event after it has already occurred.
What is a safety coach? What is their role?
Future goal. Staff who will serve as error prevention subject matter experts. Available as a safety observer and resource for staff. Representation from each department.
In 2024, what were JDCH's 3 most frequent HACs which resulted in serious harm?
1) CLABSI
2) UE
3) DART
What is the Swiss cheese model of error prevention?
A safety model showing how multiple layers of defense (cheese) reduce the chances of an error reaching the patient.
What are the 3 main components of SPS' Culture Wave? Where is JDCH at in our Culture Wave Journey?
Error Prevention, Cause Analysis, and Leadership Methods
Error prevention strategies were shared hospital wide via Back to Basics 2.0.
Cause Analysis teams are being formed to standardize our approach to safety event reviews, and to enhance collaboration and communication with the involved department leaders.
What are the 6 SPS Proactive Safety Tools? How can I begin to use them?
Proactive Safety Huddles
Leadership Rounds
Learning Teams
Simulation
Walk Through Talk Through
Bowtie Analysis
Contact your project manager, Patrick Guyer!
How can you get involved?
Contact Patrick Guyer, SPS Program Manager!
Afterwards, consult your supervisor for approval.