What is patient safety? Patient safety is the aspect of healthcare that emphasizes the reporting, analysis, and prevention of medical errors that often lead to unwanted or harmful events and what can be done to prevent them from occurring.
Baystate Health (BH) has created a culture that encourages open, non-punitive error reporting, with professional accountability, as part of its desire to create a safer environment for patients, visitors and employees. The cornerstone of the safety culture is identifying adverse events. Knowing what actions and decisions led to a safety event is important in order to understand and correct systemic errors and to plan improvements. Besides the Safety Reporting System (SRS) in which employees report all events and near-misses, global trigger tools, serious reportable events (SRE), patient safety indicators (PSI), hospital-acquired conditions (HAC), clinical risk management (claims) including review, and mandatory reporting of “never events” are also reliable sources of information. “Never events” and hospital-acquired conditions are lists of reasonably preventable events so serious that they should never happen (e.g., surgery on the wrong body part, mismatched blood transfusion). These events occur when there is a failure in the delivery of healthcare services, too often resulting in unintended injury, illness or death. The lists have been endorsed by the Centers for Medicare and Medicaid Services, The Joint Commission and the National Quality Forum. To see a complete list of never events, please click here: Never Events
The SRS provides BH with a timely, standardized system for collecting and processing information on all safety events. With SRS, reported events are classified by event type and cause, using a standardized description and classification scheme and can be compared with other like facilities using the SRS. The current reporting process can be done by completing a paper-based form or by using the web-based data entry application, and provides automated notification of each report to ensure timely attention, evaluation, and if need be, intervention.
Safety events are analyzed, categorized, and used to develop prevention interventions and to drive improvement. Unit-specific information is shared with all staff to help heighten awareness and encourage unit-based problem solving. By keeping all reported data anonymous, BH has focused on understanding the “what” and “how,” and not the “who” behind events.
Trend data is provided to each unit and shared with clinical leadership, the service-specific performance improvement team, the Nursing Clinical Practice Committee, the Performance Improvement Council, and the Board of Trustees.
BH was one of the first health systems in the nation to begin “Senior Leader Safety Walk Rounds.” Senior management makes regular rounds, discussing patient safety issues and SRS reports with direct care staff on all hospital units. This allows senior leaders to see first-hand the work environment and potential risks that are encountered every day, to dedicate resources in a timely manner, and to hear directly from front line staff their thoughts on what and when the next event will occur.
BH was also one of the early adopters of “learning” from near-miss and actual events. Each event is reviewed and considered an opportunity to learn about our processes and why they failed. That information is used to redesign the flawed process and to prevent it from occurring in the future. Additionally, a standardized process and accompanying tool, “Medical Error Algorithm,” have been developed and implemented to ensure all events are consistently investigated and managed in an objective way.
Baystate Health Ambulance
BHA has created a safer environment for patients and employees by improving the safety of our patients and staff during transports.
- BHA is the recipient of the Baystate Medical Center President's Safety Award for ambulance safety enhancements in patient and staff protection.
- Safety enhancements include:
- Improvement in patient and staff restraint systems, including safety nets and 4-point seatbelt restraints for staff.
- Upgrade of transport stretchers with improved stability and weight allowances for patients.
- Improved lighting systems for public awareness and ambulance safety during response and transport, along with scene safety.
- All ambulances are now equipped with power stretchers to reduce injury to staff and to improve patient comfort during patient movement.
Baystate Medical Center
BMC continues to create a safer environment for patients, visitors, and employees by increasing staff awareness, providing ongoing staff education, having unit-based Senior Leader Safety Walk Rounds, and developing a patient safety brochure, “Partners in Caring.”
- Other enhancements that have been put in place include:
- A patient identification policy
- Patient ID band checks at change of shift rounds
- Changes to our computerized physician order entry system
- Numerous medication safety changes
- Bar coding to optimize patient identification, and to reduce specimen labeling and medication administration errors
- Smart PYXIS for dispensing medications on the nursing units
- Development and implementation of new count and traffic policies in the OR
- Omissions in care identified through SRS have resulted in the completion of root cause analyses for vaccine administration and delivery of discharge instructions for selected patient populations.
- Initiation of the “Good Catch” program to encourage staff to report events that impact patient safety at BMC has been well received and has uncovered several improvement opportunities.
- Education and training for new SRS system (implemented in 2011) is ongoing and reporting for 2012 has increased.
Additionally, the Agency for Healthcare Research and Quality’s (AHRQ) “Hospital Survey on Patient Safety Culture” has been used in selected areas to obtain baseline scores prior to implementing models such as team training. Comparing the results from BMC with national results has helped to focus our work on areas our direct patient staff has identified as at-risk areas.
Baystate Mary Lane Hospital
Patient safety awareness is liberally encouraged regardless of a staff member’s particular role in the organization.
- SRS data is viewed regularly for situations requiring prompt attention.
- All entries are compiled and harm scores, event type and details are analyzed to identify trends and construct performance improvement plans.
- Newly hired employees are instructed step-by-step in the use of SRS.
Baystate Franklin Medical Center
Our culture of safety continues to grow with well-supported initiatives, such as:
- Scannable patient identification bands
- Computer-controlled medication dispensing
- Implementation of additional modules of the electronic medical record (EMR)
- Enhanced reporting of safety events and near misses
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