The Safe Day Call: Reducing Silos in Health Care Through Frontline Risk Assessment

Paterson, C; Miller, Kristen; Benden, Mark E.; Shipp, Eva M.; Pickens, Adam; Wendel, Monica L.; Pronovost, Peter J.

doi:10.1016/s1553-7250(14)40061-8

Cited by 5 publications

(3 citation statements)

References 10 publications

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“…PSO safety huddles are a variation on the daily safety brief held by many participating hospitals and a novel example of a safe table. 20 Designed to broaden and hasten opportunities for shared risk identification, participants voluntarily ask for help or report a risk warning to other organizations. These early warnings have involved device- and medication-related harm or near misses, outbreak trends, various process failures, unanticipated communication breakdown, and safety challenges associated with COVID response.…”

Section: Methodsmentioning

confidence: 99%

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The Child Health PSO at 10 Years: An Emerging Learning Network

Levy¹,

Conrad

Kemper

et al. 2021

Pediatric Quality &Amp; Safety

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Introduction: The 2005 Patient Safety and Quality Improvement Act, actualized as a Learning Network (LN), has enabled the Child Health Patient Safety Organization (PSO) to play a vital and novel role in improving the quality and safety of care. This article describes the Child Health PSO and proposes PSOs as a new construct for LNs. Methods: A PSOs ability to affect patient care depends on member organizations’ integration of PSO output into their individual Learning Healthcare Systems. Therefore, the Child Health PSO developed tenets of an LN to improve member engagement in PSO outputs. Results: All Child Health PSO members participate in case-based learning, requiring ongoing and robust participation by all members. The engagement has been strong, with 86% of children’s hospitals achieving a case learning activity metric and 60% of children’s hospitals submitting cases. From this LNs perspective, 53% of children’s hospitals are considered highly engaged. Conclusions: In the last 10 years, the Child Health PSO has evolved as a viable LN and, to sustain this, has set a target of 100% of participating children’s hospitals being highly engaged. The previously inconceivable notion of sharing information to improve patient safety among hospitals is now an expected result of the formation of trusting relationships under a federally certified PSO. According to participants, collaboration is an essential element that empowers individual children’s hospitals to eliminate preventable harm.

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Section: Methodsmentioning

confidence: 99%

Section: Safe Tables "Safe Tablementioning

confidence: 99%

The Child Health PSO at 10 Years: An Emerging Learning Network

Levy¹,

Conrad

Kemper

et al. 2021

Pediatric Quality &Amp; Safety

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“…A mature culture of safety focuses on the system and the impact on people, elevating psychological safety, concentrating on why the event occurred within that environment; and why the established redundancies within the system were not effective in aborting the event. Changing the culture of safety where the outcome (harm) is not the center of the investigation to one where the investigative questions move away from what happened and who was involved, increases the trust in the evaluation process and decreases the fear of participating in the event assessment [53]. Emphasizing on the individual participants and not the system assessment results in further degradation of the culture, prevents people from speaking up, and leads to more cover-ups due to concerns of being labeled as incompetent as well as enhances the fear of retaliation.…”

Section: Causalitymentioning

confidence: 99%

Patient Safety in the Critical Care Setting: Common Risks and Review of Evidence-Based Mitigation Strategies

Arteaga¹,

Bacu²,

Franco³

2023

Contemporary Topics in Patient Safety - Volume 2

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The Intensive Care Unit (ICU) has evolved in the last 50 years. This evolution’s main drivers include equipment and software improvements, the patient safety movement, and a better pathophysiological understanding of critical illness. There is mounting pressure from accreditation agencies, governmental regulation, financial challenges, operational dynamics, staffing changes, and increased acuity affecting-ICU care delivery and impacting patient safety. There are higher than ever expectations to improve clinical outcomes after an intensive care stay, to enhance patient safety, to increase family involvement in decision making, and merge the multidisciplinary medical experience into an effective teamwork. Leadership focus is directed towards increasing diversity and inclusion in the workforce while enhancing psychological safety. This review addresses the common risks for patient safety in the intensive care setting and describes the changes in mindset and application of evidence-based mitigation strategies.

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