Monthly Archives: March 2020

Our Stories: Patient Safety is a Team Sport

March 8 to 14 has been designated as Patient Safety Awareness Week. The Institute of Medicine’s report, To Err is Human, has been transformational for patient safety. The report brought to light that many errors in health care result from a culture and system that is fragmented and that improving health care requires a team approach. Several major points in the report are that errors are common and costly, systems-related problems cause errors, errors can be prevented, and safety can be improved. Twenty years later, the Patient Safety movement has produced learnings that demonstrate significant improvement in the care patients receive, and conversely that many opportunities remain.

Health care organizations are in a constant state of stress due to high patient volumes, complex, sicker patients and staff shortages. UI Hospitals & Clinics is not protected from these challenges. Daily we prioritize and re-prioritize throughput issues, discuss barriers to discharge, navigate the impact of behavioral health on patient and staff safety, accommodate medication shortages, and at this point in time, strategically plan how we will respond to an impending pandemic related to coronavirus.

Who we are as an organization and how we responsibly engage in the work of patient safety could not be more important. In the past five years much work has been accomplished to implement and operationalize a quality and safety structure that has reduced fragmentation and emphasized alignment of quality and safety work across the organization. This alignment creates greater critical mass and collective voice around quality and safety priorities, and in turn establishes health care as team sport, allowing us to continue to improve the care we provide patients.

In addition, senior leadership continues to invest in tools and programs that will influence UI Hospitals & Clinics’ ability to achieve and sustain excellence in care delivery free of preventable harm. On March 9, we will launch a new incident reporting system, Riskonnect. The new system is intuitive with a user-friendly platform, provides improved detail in event reporting and analytics, and system availability of Root Cause Analysis (RCA), peer review, and claims modules providing one protected location for all event review information. This past week, training was provided on how to communicate and disclose information to patients and families that have experienced a harm event. In the near future, we will make a decision on a Just Culture consultant who will partner with us over the next couple of years to establish systems of strong accountability for safe practices in which healthcare is delivered.

As we approach Patient Safety Awareness Week, take the opportunity to reflect on the many ways in which we contribute to the provision of safe, high quality patient care. I invite you to participate in the activities that have been planned here at UI Hopsitals & Clinics. And last but not least, I encourage you to take the opportunity to thank the members of your team, those you work closely with each and every day, to ensure we make a difference in the lives of those we care for!

Beth A. Hanna, BSN, RN, MA
Director, Quality Improvement Program