Closing the Loop on Patient Safety:

Quality Forum 2013

•Naomi Erickson, BSN, MHS•Maureen MacKinlay, MSW

Disclosure

Naomi Erickson & Maureen MacKinlay both work for Interior Health

Neither Naomi nor Maureen have any relevant financial or non-financial relationship to disclose

Traditional thinking about patient safety

Well trained conscientious employees didn’t make errors

Error = incompetence & stigma Punishment = more careful employees

This kind of toxic, blaming culture resulted in reduced compliance with reporting

Learning opportunities were limited (Emanual, et al, 2005)

Contemporary Thinking 1990’s – shift to systems thinking Analysis to better understand the

elements that influence safety Sharing information More information shared = better learning

industry wide Patient Safety Learning System (PSLS)

PSLS Offers process for reporting incidents Has ability to produce reports, showing

trends PSLS is a tool to report safety events but

on its own, it fails to feedback to the reporter and others systems improvements

The result of not sharing our learning can be repeated, preventable errors

Why is this an issue? Staff feedback is that they are not aware

of actions resulting from their report Staff are not aware of all quality

improvement initiatives Missed opportunity to look for alternative

answers to complex problems Missed opportunity to share learning Missed opportunity to raise awareness of

safety

Options for Closing the Loop

Obligation of leaders to share learning with patients, staff and others

• Staff meetings• Patient Safety Walkabouts• Newsletters• Safety Huddles• Posters

Posters highlight: What happened Significance of the problem Multi-factors that contributed to

incident• Environmental• Systems• Human resources

Changes made to mitigate future occurrences of the incident

Applicability of learning

Evaluation of Feedback Method Programs at two tertiary psychiatric sites

were surveyed to determine:• Were the posters a way an effective

way to share learning?• Did it change the employee’s

perception of the organization’s commitment to safety?

Results of survey showed posters were an effective way to share learning.

Transformed Organization Lessons shared with other mental health

programs (knowledge translation) Highlighting learning from one experience

is validating to staff who have taken time to report

Discussion about patient safety incidents involves staff in problem solving

Reporting in the PSLS is reinforced Improved Culture of Safety and Learning

References Emanual, L., Berwick, D., Conway, J. et al (2008).

What exactly is patient safety? In Henriksen, K., Battles, J, Keyes, M. et al, Eds., Advances in patient safety: new directions and alternative approaches (Vol. 1 Assessment). Rockville (MD): Agency for Health care Research and Quality. Advances in Patient Safety. 2008 Aug. Available on line at www.ahrq.gov/advances2/.

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Questions