Reporting Culture

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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)

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Johns Hopkins University

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

101 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

[MUSIC]

In this video, we're going to to talk about reporting culture.

You may recall that patient safety culture is an aspect of organizational culture,

that really focuses on attitudes, values, structures, and processes for

patient safety.

James Reason had identified four domains of an informed safety culture.

The first domain is reporting culture.

When we think about event reporting, reporting culture relates to things like

if staff know how and when to report, to whom errors get reported.

And if staff report both harmful and near miss reports.

The second domain, just culture, which is really around how we appropriate blame,

relates to a lot of our processes for reviewing and investigating errors.

Are people being punished for the errors that they make?

And how are events handled when staff cut corners?

The third domain, flexible culture is really aimed that understanding how

readily people can adapt to sudden and radical increments and pressure.

When we think about this in terms of patient safety event reporting,

questions we can ask ourselves to understand this is

what work arounds exist and for what purposes?

And how are hazards mitigated?

The last domain is around learning culture.

When we think about how this relates to event reporting,

it relates to wondering if staff know how and what to report.

To whom do errors get reported?

And do staff report both harmful and near miss reports?

There are all sorts of factors documented in the literature

that influence reporting.

There are individual factors,

if staff know how to actually use the event reporting system.

Often staff struggle with what should count as an event report.

Who should report?

Sometimes there's confusion over whether it should be a nurse, or

another person on the care team.

There are often time constraints and the complexity of our reporting forms.

But there's also an equally important

bucket of factors that influence reporting.

And those are the organizational factors.

Is there a punitive response when staff report?

Are actions taken to actually mitigate risks?

And if not, will staff continue to report?

Are the events likely to lead to change?

And do staff perceive a value?

Additionally, event reporting data is often peer review privileged and

protected.

And the ability to transparently share these events at

the organizational level can be challenging,

which may impact staff member's perceptions related to event reporting.

There's an emerging body of science around voice behaviors that comes from the high

reliability industry.

Voice provides data to readily detect error and

get information about emerging trends.

Voices from below such as employees or

patients increase the signal leaders have available to make decisions.

Leaders can promote and respond to a voice in several ways.

They can encourage diversifying reporters.

Often nurses are the most frequent reporters, but

we can encourage residents and physicians to report as well.

They can ensure a Just Culture response to those who speak up.

And they can take actions to make situations better as a response to voice.

Some strategies for promoting reporting include revising policies to incorporate

just culture responses, to reward good catches and

identify second victims, to identify expectations for

event review and follow-up, to streamline reporting modalities.

So that you're collecting only necessary information, and

to avoid the black hole net.

This can be done by reviewing events submitted, considering feedback

to reporters and communicating lessons learned throughout the organization.

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