Patient Safety & Relations Teams
Name the patient safety specialists (at least one)?
Sheri Handy, RN
Emily Thorson, RN
Melissa Lincoln, RN
Nicole Peterson, RN
What is patient advocacy?
Be a voice for patients
What does it mean to be a highly reliable organization?
A high reliability organization (HRO) is defined as an organization that has maintained high levels of safety, quality, and efficiency over an extended period.
The HRO framework has three Pillars: 1) Leadership commitment; 2) culture of safety; and 3) process improvement
What are examples of surgical adverse health events?
-Wrong Body Part
-Wrong Patient
-Wrong Surgery or Procedure
-Retained foreign object
-Unexpected Death
What are ways in which you can speak up about a potential or actual safety concerns?
Report to leadership
Entering an event into AWARE
Name the patient relations team members (at least one)?
Trisha Martin
Liz Berry Epperson
Brittany Mann
What does patient relations do?
Listening ear for patient/family concerns, facilitates answering patient/family concerns by liaising with applicable clinical leaders, and assists with formalizing responses to these concerns.
What is preoccupation with failure?
Everyone is aware of and thinking about the potential for failure..
Attitude of "Prove to me it is safe versus prove to me it is unsafe"
Near misses are viewed as opportunities to learn about systems issues and potential improvements, rather than evidence of safety.
What are examples of product of device adverse health events?
-Death/disability due to contaminated drugs, device, biologics
-Death/disability due to device use or function not as intended
-Death/disability due to intravascular air embolism
Who is responsible for Just Culture?
Everyone of us
Who is the AWARE system administrator?
Kris Young
What is Nurse Practice Review and Clinician Peer Review?
Coordination of review when nursing and/or clinician standards of care are in question
What is Situational Awareness or Sensitivity of Operations
"Big Picture Understanding"
People understanding what is going on around them and how the current state might support or threaten safety
What are patient protection adverse health events?
-Patient without capacity discharged to wrong person
-Death/serious injury due to patient disappearance
-Patient suicide/attempted suicide/self harm while under our care
What is a Blame Culture?
Opposite of just culture:
A culture where employees pass responsibility to others for mistakes or lack of accountability
Who is the Director of patient safety & accreditation?
Hailey Corrigan
Emily Mishek
What is AWARE?
Internal software program for reviewing and monitoring of actual and/or potential safety events
What is deference to frontline expertise?
Appreciating that people closest to the work are the most knowledgeable about the work.
Everyone is expected to share concerns with other and the organizational climate is such that all staff are comfortable speaking up about potential safety problems
What are examples of care management adverse health events?
-Death or serious injury due to medication error
-Death or serious injury due to unsafe administration of blood/blood product
-Maternal death or serious injury in labor or low-risk pregnancy
-Death or serious injury of neonate in labor or low-risk pregnancy
-Pressure Injuries (stage 3, 4, or Unstageable)
-Artificial insemination with wrong donor egg/sperm
-Death or serious injury due to fall
-Irretrievable loss of an irreplaceable specimen
-Death or serious injury due to lack of follow-up/communication
What is the definition of Just Culture?
A concept related to systems thinking which emphasizes that mistakes are generally a product of faulty organizational cultures, rather than solely brought about by the person or persons directly involved.
Who is the VP of Quality & Patient Safety?
Matt Westerlund
What is adverse health and sentinel event reporting?
Managing risk for the organization through identification and investigation of a serious safety event.
What is commitment to resilience?
Learning from past mistakes - understanding the nature of system failures
What are examples of environmental Adverse Health Events?
-Death/serious injury due to electric shock
-Wrong gas/contaminated line
-Death/serious injury due to burn
-Death/serious injury due to use or lack of restraints
What are three elements of Just Culture? (name at least one)
1. building awareness
2. implementing policies that support just culture
3. building just culture principles into the practices and processes of daily work