Patient safety reporting systems: Sustained quality improvement using a multidisciplinary team and "good catch" awards

Joint Commission Journal on Quality and Patient Safety

Volumn 38, Issue 8, 2012, Pages 339-347

  Herzer, Kurt R ^a   Mirrer, Meredith ^b   Xie, Yanjun ^b   Steppan, Jochen ^a   Li, Matthew ^b   Jung, Clinton ^b   Cover, Renee ^c   Doyle, Peter A ^c   Mark, Lynette J ^b  

^a JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b Department of Anesthesiology and Critical Care Medicine ^*  (United States)

^c JOHNS HOPKINS HOSPITAL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADVISORY COMMITTEE; ARTICLE; AWARDS AND PRIZES; DOCUMENTATION; HUMAN; LEADERSHIP; MEDICAL ERROR; METHODOLOGY; OPERATING ROOM; ORGANIZATION; ORGANIZATION AND MANAGEMENT; PATIENT SAFETY; SAFETY; STANDARD; TEACHING HOSPITAL; TOTAL QUALITY MANAGEMENT; UNITED STATES;

ADVISORY COMMITTEES; AWARDS AND PRIZES; DOCUMENTATION; HOSPITALS, TEACHING; HUMANS; LEADERSHIP; MARYLAND; MEDICAL ERRORS; OPERATING ROOMS; ORGANIZATIONAL CULTURE; PATIENT SAFETY; QUALITY IMPROVEMENT; SAFETY MANAGEMENT;

EID: 84864245630     PISSN: 15537250     EISSN: None     Source Type: Journal    
DOI: 10.1016/s1553-7250(12)38044-6     Document Type: Review

References (28)

1. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000.
2. Frankel A, et al. Revealing and resolving patient safety defects: The impact of leadership WalkRounds on frontline caregiver assessments of patient safety. Health Serv Res. 2008;43(6):2050-2066.
3. Frankel A, et al. Patient Safety Leadership WalkRounds at Partners Healthcare: Learning from implementation. Jt Comm J Qual Patient Saf. 2005;31(8):423-437.
4. Sexton JB, et al. The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006 Apr 3;6:44.
5. Anderson E, et al. Medical students benefit from learning about patient safety in an interprofessional team. Med Educ. 2009;43(6):542-552.
6. Odwazny R, et al. Organizational and cultural changes for providing safe patient care. Qual Manag Health Care. 2005;14(3):132-143.
7. Pronovost PJ, et al. Toward learning from patient safety reporting systems. J Crit Care. 2006;21(4):305-315. (Pubitemid 44908870)
8. Association for the Advancement of Medical Instrumentation (AAMI). Medical Devices-Application of Risk Management to Medical Devices. Arlington, VA: AAMI, 2007.
9. Haig KM, Sutton S, Whittington J. SBAR: A shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32(3):167-175.
10. Herzer KR, et al. Designing and implementing a comprehensive quality and patient safety management model: A paradigm for perioperative improvement. J Patient Saf. 2008;4(2):84-92.
11. Vincent C. Incident reporting and patient safety. BMJ. 2007 Jan 13;334(7584):51. (Pubitemid 46122221)
12. Surowiecki J. The Wisdom of Crowds: Why the Many Are Smarter than the Few and How Collective Wisdom Shapes Business, Economics, Societies, and Nations. New York City: Doubleday, 2004.
13. Nakajima K, Kurata Y, Takeda H. A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital. Qual Saf Health Care. 2005;14(2):123-129. (Pubitemid 40523857)
14. Pronovost PJ, et al. Senior executive adopt-a-work unit: A model for safety improvement. Jt Comm J Qual Saf. 2004;30(2):59-68.
15. UHC. UHC Patient Safety Net® Learn More. Accessed Jun 26, 2012. https://www.uhc.edu/UHCPSN.htm.
16. Szekendi MK, et al. Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety. Jt Comm J Qual Patient Saf. 2010;36(1):3-9.
17. Accreditation Council for Graduate Medical Education. Core Competencies. Michael G. Stewart. 2001. Accessed Jun 26, 2012. http://www.acgme.org/acWebsite/ RRC-280/280-coreComp.asp.
18. Wolters Kluwer Health. Drug Facts and Comparisons. St. Louis: Wolters Kluwer Health, 2012.
19. Institute for Safe Medication Practices. Another Heparin Error: Learning from Mistakes So We Don-t Repeat Them. ISMP Medication Safety Alert! Nov 29, 2007. Accessed Jun 26, 2012. http://www.ismp.org/newsletters/acutecare/articles/ 20071129.asp.
20. The Wall Street Journal. Heparin Overdoses Hit Babies in Texas Hospital. Wall Street Journal blog entry by Francis T. Jul 9, 2008. Accessed Jun 26, 2012. http://blogs.wsj.com/health/2008/07/09/heparin-overdoses-hit-babies-in-texas- hospital/.
21. US Food and Drug Administration. Baxter Issues Urgent Nationwide Voluntary Recall of Heparin 1,000 Units/ml 10 and 30ml Multi-Dose Vials. Jun 18, 2009. Accessed Jun 26, 2012. http://www.fda.gov/Safety/Recalls/ArchiveRecalls/ 2008/ucm112352.htm.
22. Pronovost PJ, et al. Reducing health care hazards: Lessons from the Commercial Aviation Safety Team. Health Aff (Millwood). 2009;28(3):479-489.
23. US Food and Drug Administration. MedSun: Medical Product Safety Network. Accessed Jun 26, 2012. http://www.fda.gov/MedicalDevices/Safety/ MedSunMedicalProductSafetyN etwork/default.htm.
24. Pronovost PJ, et al. Using incident reporting to improve patient safety: A conceptual model. J Patient Saf. 2007;3(1):27-33.
25. Bagian JP, et al. Improving RCA performance: The Cornerstone Award and the power of positive reinforcement. BMJ Qual Saf. 2011;20(11):974-982.
26. Scott DR, et al. A novel approach to increase residents-involvement in reporting adverse events. Acad Med. 2011;86(6):742-746.
27. Gandhi TK, et al. Creating an integrated patient safety team. Jt Comm J Qual Saf. 2003;29(8):383-390.
28. Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: An elusive target. JAMA. 2006 Aug 9;296(6):696-699. (Pubitemid 44200641)