What methods can you use to identify patient safety improvements?

One weakness of RCA is not embedding the culture measurements in an RCA and really thinking about it in a linear fashion, while actually in an HRO we need to commit to "reluctance to simplify" and the root causes of an incident can be beyond what was tracked as sequence of events.

RCA is limited by its linear approach and can disproportionately focus on acts of omission or commission by actors rather than identifying the role other system components have in factors that lead to adverse events. Tools such as SEIPS offer greater insights and reflect the Donebadian model of healthcare. It’s worth bearing in mind that RCA was originally a production system analysis tool hence its linearity.

The first phase in the ADDIE model is to analyze the training need. Needs assessment guides training development Use your program goal to help you determine your needs assessment goal or the desired outcome of this type of evaluation. Evaluation questions will help focus your information collection about identifying the gap source and potential solutions. Example Your program goal is to vaccinate 70% of your population. Your vaccination rates are lower than your program wants them to be (i.e., the gap). Why are the vaccination rates low? If you learn that one source is a lack of knowledge or skill among newly hired staff members for providing vaccinations (performance gap), then you would want to consider training as a solution.

FMEA is really underutilized in healthcare... maybe because we are still more reactive to events. We do way more RCAs than FMEA right? I have used FMEA as a tool to identify and address potential failures in the sepsis management process. If you think of the failure modes, they can be: Missed opportunities to recognize sepsis early on, incorrect antibiotic selection, inadequate fluid resuscitation, delayed initiation of vasopressor therapy Severity: Increased risk of death, increased length of hospital stay etc. Occurrence: How often the failure mode is likely to occur Detection: How likely the failure mode is to be detected We published this FMEA work in 2017 in the Journal of Patient Safety https://www.jstor.org/stable/26637508

The reason I love PDSA and utilize is frequently is because: It utilizes a systematic approach, has adaptability, fosters a culture of ongoing improvement, is data driven, assures engagement and collaboration and finally, helps decrease errors through studying and testing.

PDSA is one of the most powerful and useful methods in Safety and Quality because of its simplicity and the ability for a small group of staff to implement. It can be used in a small ICU unit or a systemwide pharmacy in a complex healthcare system! A a loop feedback mechanism, changes and re-tweaking can easily be made at any of those four phases!

As leaders, we should always promote a culture of patient safety and awareness. Unfortunately, some organization are so punitive when errors happen preventing the staff to speak truth to power leading to inaccurate data collection to drive change

I think one of the most important approaches to address the required patient safety improvements is the proper patient safety related Key Performance Indicators (KPIs) selection including results of patient safety culture surveys. Another example is the Hospital-Acquired Infection Rates. Monitoring these indicators helps evaluate the effectiveness of infection control measures and identify areas requiring improvement such as Bundles compliance.

Patient feedback is undeniably crucial, but in skilled nursing facilities, residents may withhold concerns due to fear of staff retaliation, especially when they have no immediate discharge plans. Living in the facility for an extended period, they're susceptible to potential changes in care by staff, who might perceive their feedback as criticism. To overcome this challenge, it's essential to establish trust and provide multiple channels for anonymous and confidential feedback. Encouraging an open, non-punitive culture, along with regular opportunities for residents to express their concerns, can empower them to share their experiences without fear, ensuring that the quality of care remains a top priority.

Patient feedback is crucial to solidifying changes or improvements. Administration can try their best to "think like the patient" or rely on their past experiences, but we forget that we live this world inside and out and no matter, causing any interaction within the healthcare environment to be influenced by our knowledge. We need to utilize our patients and their recent experiences to mold our changes. We also need to expand on how we seek and receive feedback, mailed patient surveys are antiquated, costly, and the population that would use them is declining. Embrace free, modern forms of receiving feedback.

As a nurse leader, one of the things I pride myself on is the quest to improve resident care and safety standards. I have an open door policy encouraging staff to report incidents without fear of retribution. Anonymity and a blame free culture is imperative to improve the flow of communication.

A patient is as safe as the caregiver providing his care. Have you ever wondered how healthcare experience would look like with a focus on caregiver experience? Healthy and well clinicians lead to healthy and well and safer healthcare. We recently completed a continuous improvement project by using an A3 framework to explore how supporting the workplace experience of a nursing unit with an intentional focus on humanizing with empathy changed the care approach. Interesting 🧐 an uptick of positivity and empathy in the workplace appeared to enhance a sense of community and focus on the moment for best care and safety outcomes… more to come.