Implementing a hospitalwide patient safety program for cultural change

Joint Commission Journal on Quality and Safety
Max M CohenCarolyn A Roth

Abstract

After focus groups revealed that staff perceived a punitive culture, Missouri Baptist Medical Center (MBMC) embarked on a comprehensive patient safety program, which was initially directed at creating a just culture of patient safety. A series of structures, processes, and initiatives were introduced to change the attitudes of management and staff toward human error, to communicate broadly with staff and the community, and to provide feedback on leadership's responses to specific events. All events reported were tracked continuously and recorded each month on a spreadsheet. Total medical events reported by staff increased significantly (p < .001) from 35 to 132 per 1,000 patient days. Reports to the hotline alone increased significantly (p < .001) from 3 to 23 per 1,000 patient days, and the proportion of callers who left their name increased significantly (p < .001) from 30% to 61%. Survey results from staff showed a small but significant increase in awareness of patient safety and in comfort with reporting. The implementation of a carefully planned and orchestrated series of interventions designed to improve a hospital's culture of patient safety can, if led by senior hospital executives, lead to a substantial, profound, and ...Continue Reading

References

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Citations

Jul 22, 2009·Health Services Research·Sara J SingerAmy K Rosen
Feb 27, 2009·Medical Care Research and Review : MCRR·Christine W HartmannDavid M Gaba
Jul 10, 2007·International Journal of Gynaecology and Obstetrics : the Official Organ of the International Federation of Gynaecology and Obstetrics·A Nabhan, M S Ahmed-Tawfik
Jun 12, 2013·Evaluation & the Health Professions·Lianne JeffsElla Ferris
May 1, 2017·Basic & Clinical Pharmacology & Toxicology·Trine R H NielsenStig E Andersen
Sep 6, 2018·Journal of Healthcare Risk Management : the Journal of the American Society for Healthcare Risk Management·Ruth CardielloSharon Kiely
Aug 29, 2009·Journal of Manipulative and Physiological Therapeutics·Beatrice Zaugg, Martin Wangler

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