Partners Commitments to Patient Safety
Patient Safety leaders across Partners Healthcare have put forth “The Partners Commitments to Patient Safety," a set of guidelines to enforce safety throughout the network. The CMO-CNO Council approved these commitments in March as a measure to continue to reinforce a culture of safety where adverse events and errors can be discussed openly to improve systems. The Partners patient safety leaders are holding a retreat to discuss the implications of these commitments and to develop strategies to make these commitments real in our institutions.
BWH has aligned our patient safety initiatives with the “Partners Commitments to Patient Safety,” which are as follows:
WE SUPPORT THE EFFORTS OF EVERY MEMBER OF THE HEALTH CARE TEAM TO DELIVER THE BEST CARE POSSIBLE
The implication of this commitment is to “deliver the best care possible.” To this end, we need to differentiate between individual and system factors that contribute to error. We need to commit to changing processes and systems that are unsafe to reduce harm, although not minimizing individual accountability. Teamwork training and simulation are some strategies employed to achieve this goal.
WE PROMOTE OPEN DISCUSSION WITHIN OUR ORGANIZATIONS TO LEARN ABOUT ADVERSE EVENTS AND POTENTIAL CAUSES OF HARM
The implications of this commitment are the concept of “open discussion” and “sharing what we learn.” Patient Safety Executive WalkRounds continue to be an effective means of open discussion with senior leadership regarding actual or potentially harmful systems. Other strategies may include safety briefings or standardized patient sign-out methods for both physicians and nurses. We share lessons learned within and across hospitals through educational opportunities such as grand rounds or M&M conferences and ongoing patient safety collaboratives.
WE PROMOTE INTERDISCIPLINARY DISCUSSION AND ANALYSIS OF ADVERSE EVENTS AND POTENTIAL PATIENT HARM
Implications of this commitment include “interdisciplinary discussions” and understanding that “patient input is invaluable.” Sentinel event analysis or root cause analysis involves the input of multidisciplinary teams to identify and evaluate the potential systems flaws. We have included patients in focus groups for various improvement projects in the Obstetrics Department and the newborn ICU. We have developed a patient safety brochure to be included in each admissions packet and available in the outpatient clinics.
WE WILL ACT TO IMPROVE SAFETY BY IMPLEMENTING CHANGES BASED ON OUR ANALYSIS OF ADVERSE EVENTS
The implication of this commitment is “act to improve safety.” The Drug Safety Committee reviews the trends of medication errors to make safety interventions. We strive to ensure ownership and timely follow up of proposed action items.
WE WILL INFORM PATIENTS AND FAMILY MEMBERS, HEALTH CARE PROVIDERS, LEADERSHIP AND TRUSTESS ABOUT ACTIONS THAT HAVE BEEN TAKEN TO IMPROVE PATIENT SAFETY
Senior leadership supports safety as a high priority agenda item. The Patient Safety Team along with senior leadership provides feedback to the executives and to the board of Trustees. Increased feedback is necessary for the front line staff to promote ongoing safety discussions.
WE WILL MEASURE OUR SUCCESS IN PROMOTING AN ENVIRONMENT OF PATIENT SAFETY
Improvement processes will be measured to gage our success and guide further improvement.