The following are key components and processes essential to the effective functioning of the overall Patient Safety Program.  

Staff is encouraged and expected to report adverse events or near misses that affect or have the potential to negatively affect patient outcomes. Information obtained from the reporting process is collected in a database so that issues and trends can be identified. The main purpose of collecting this data is not punitive but to identify systems and processes that need improvement.

When a serious unexpected adverse outcome occurs, the Root Cause Analysis process is used to determine the most basic or immediate factor(s) or causes of variation in performance which lead to the adverse outcomes for the patient. This formal process is utilized by a team of involved managers and staff to determine how the process failed and where improvements need to be made.

Whenever areas for improvement are identified, an important step of the process is to develop the actions that need to be taken and assign responsibility for implementation. This is accomplished through various Departments, Committees and Task Forces throughout the organization. The Care Council at each facility, which is a group of Senior Leaders and Managers, is responsible to be sure that appropriate actions are taken to reduce risk and improve patient safety.

Once actions are taken it is important that the organization monitor progress to be sure that improvement is made and sustained. Again, the Care Council is responsible for ensuring that monitoring of key processes affecting patient care and safety is accomplished. They are also responsible for reviewing monitoring data on an ongoing basis and taking appropriate actions.

One of the methods we utilize to assess our safety practices is the utilization of the Joint Commission on Accreditation of Health Care Organization's Sentinel Event Alerts. These alerts are sent to all accredited healthcare organizations. They include information regarding sentinel events (events with serious adverse outcomes for patients) which have occurred at other organization(s). Safety strategies to prevent such an occurrence are included. We utilize this information to review our current practices and implement the appropriate safety practices and preventative measures, not already in place.

 
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