Event Reporting and High Reliability

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來自 Johns Hopkins University 的課程

Setting the Stage for Success: An Eye on Safety Culture and Teamwork (Patient Safety II)

71 個評分

Johns Hopkins University

Setting the Stage for Success: An Eye on Safety Culture and Teamwork (Patient Safety II)

71 個評分

課程 2（共 7 門，Specialization Patient Safety）

Safety culture is a facet of organizational culture that captures attitudes, beliefs, perceptions, and values about safety. A culture of safety is essential in high reliability organizations and is a critical mechanism for the delivery of safe and high-quality care. It requires a strong commitment from leadership and staff. In this course, a safe culture is promoted through the use of identifying and reporting patient safety hazards, accountability and transparency, involvement with patients and families, and effective teamwork.

從本節課中

Event Reporting and Second Victims

Patient safety event reports are a critical data source for identifying and mitigating harm in high reliability organizations; yet, many healthcare organizations do not take full advantage of this data. At the conclusion of this module, learners will understand how event reports should be used to design safer care systems and how organizations can provide support to staff involved in medical errors.

How to Submit an Event Report9:25

Journey of an Event Report3:04

Event Reporting and High Reliability3:28

Using Event Reports to Improve Safety and Culture3:09

Reporting Culture4:04

Using Event Reports to Design Safer Systems: Part I2:34

Using Event Reports to Design Safer Systems: Part II5:01

A Sample Event Review Meeting12:34

Introduction to the Learning from Defects Tool12:50

Disclosure of Medical Errors2:49

Second Victims7:30

Peer Support: Making a Difference for Second Victims8:48

與講師見面

Eileen Kasda

Now we're going to talk about Event Reporting and High Reliability.

If you think back to the characteristics of HROs,

these are organizations who operate in unforgiving social and political environments.

They use complex processes to manage complex technologies.

They have potential for surprises and adverse consequences.

They have limited opportunities for learning through experimentation.

They also have widespread accountability with sanctions for substandard performance.

These characteristics are incredibly similar to healthcare.

Where healthcare is different from high reliability organizations though,

is that health care does not have this collective mindfulness

enhancing their ability to identify and correct errors before they escalate.

And unfortunately, we don't have remarkably good and consistent safety outcomes.

Patient Safety Event Reporting Systems are

a fundamental component of an organizational strategy to foster a culture of safety,

and they can be used to communicate safety concerns.

Historically, event reporting systems have been designed in one of two ways.

Mandatory reporting focuses on errors that involve harm or

death and they're really designed to hold folks accountable.

Reporting of mandatory errors may often be required by regulators or accrediting bodies.

Voluntary reporting on the other hand captures a broader set of errors

and really strives to detect system weaknesses before harm occurs.

For both forms of reporting,

mandatory or voluntary reporting,

the goal is really to analyze the information and identify ways to prevent future errors.

Event reporting is a critical data source in

high risk industries but has not been leveraged to its fullest extent in healthcare.

When we think about the mindful organizing infrastructure,

event reporting is an excellent tool to embrace some of these concepts.

When we think about respectful interactions,

event reporting offers an ability for staff to

anonymously or self-identify when reporting.

When we think about heedful interrelating,

event reporting offers a way to monitor for

unintended consequences and downstream impacts of system changes.

When we look at the mindful infrastructure

the first principle preoccupation with failure,

is relevant as event reporting offers a vehicle

to identify early signals of systems issues.

The second principle, our reluctance to simplify applies as

event reporting offers an appropriate way to gather

a diverse perspective on complex system flaws.

Any staff member can submit an event.

When we think about the third principle, sensitivity to operations,

event reporting offers a convenient portal for

frontline staff to voice concerns for safety.

Event reporting systems are usually available on

all computers or other devices for an organization.

When we think about the fourth principle, commitment to resilience,

event reporting offers an opportunity to recognize staff who have gone above and beyond

to ensure patient safety as

well as to support staff who have been involved in a medical error.

The last principle deference to

expertise applies to event reporting as event reporting offers

a space for collaborative problem solving with

identifying diverse perspectives on system issues.

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