Post on 23-Nov-2018
Leadership Safety Strategies
Training - Physician, staff, and leadership *
On-line event reporting system *
Transparency*
• SSER*
• Days since last SSE*
• Employee injury rates
• Put a face on safety*
• Scorecards (HACs, AHRQ PSI)
Safe patient handling program*
Communication
• JoE boards*
• Excellence Boards*
• On line newsletters
• Home screen message
* Examples to follow 3
Serious Safety Event • Reaches the patient
• Results in moderate to severe harm or death
Precursor Safety Event • Reaches the patient
• Results in minimal harm or no detectable harm
Near Miss Safety Event • Does not reach the patient
• Error is caught by a detection barrier
or by chance
Precursor Safety Events
Serious Safety Events
Near Miss Safety Event
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A deviation from generally accepted
performance standards (GAPS) that…
Safety Structure
8
System Board
Hospital Board
Quality Steering
HRO Team
Safety Events
Team
System Safety
Steering
Hospital Safety
Committee
Sub
Sub
On-line Event Reporting
Manual (2013) Electronic (2014)
0
200
400
600
800
1000
1200
1400
February March
2013
2014
9
Transparency: Faces of Safety RD
2 years Delay in treatment
12/2/2013 EH
9 months
Failure to Rescue
6/22/2013
IZ
11 months
Delay in treatment
10/21/2013
FL 7 day old
Accidental extubation 11/18/2013
LB 17 years
Delay in Tx/SSI 12/8/2013
DB
9 years
CLABSI
12/18/13
LT
16 years
Procedural
Comp. 3 CT’s
3/3/2014
BT
5 months
Care Management
3/1/2014
MC 15 years
SSI 9/17/2013
AS 11 years
Critical airway obstruction 7/8/2013
Transparency: SSER and Days Since Last
Event
11
• 89 days since last confirmed SSE (as of 5/30/2014)
• Approximately 36 days between events
over 12 months
Transparency : CLABSI
12
• NICU – 415 days (1 year, 1 month)
• Hematology-Oncology– 167 days
• Pediatrics –1167days (3 years, 2 month)
• PICU – 597 days (1 year, 7 months)
Last Catheter-Associated Blood Stream
Infections (as of May 30, 2014)
Safe Patient Handling Program
13
2013 – 73% a reduction from
2012!
Employee Injuries Due To Moving Patients
32 20 20 18 15 9 10 15 4 0
10
20
30
40
2005 2006 2007 2008 2009 2010 2011 2012 2013
2013 – a 73% reduction from 2012!
Add’l. Leadership Safety Strategies
Safety huddles
Board involvement
Accountability
• Rounding
Recognition
18