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Fundamentals of a patient safety program

  • ALARA: BUILDING BRIDGES BETWEEN RADIOLOGY AND EMERGENCY MEDICINE
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Abstract

Thousands of people are injured or die from medical errors and adverse events each year, despite being cared for by hard-working, intelligent and well-intended health care professionals, working in the highly complex and high-risk environment of the American health care system. Patient safety leaders have described a need for health care organizations to make error prevention a major strategic objective while at the same time recognizing the importance of transforming the traditional health care culture. In response, comprehensive patient safety programs have been developed with the aim of reducing medical errors and adverse events and acting as a catalyst in the development of a culture of safety. Components of these programs are described, with an emphasis on strategies to improve pediatric patient safety. Physicians, as leaders of the health care team, have a unique opportunity to foster the culture and commitment required to address the underlying systems causes of medical error and harm.

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References

  1. Institute of Medicine, Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. In: Kohn LT, Corrigan JM, Donaldson MS (eds) National Academies Press, Washington DC

  2. Pronovost P et al (2006) Creating high reliability in health care organizations. Health Serv Res 41(4 Pt 2):1599–1617

    Article  PubMed  Google Scholar 

  3. National Quality Forum. Safe practices for better healthcare. Available via www.qualityforum.org/projects/completed/safe_practices. Cited 9 Feb 2008

  4. Frankel A, Graydon-Baker E, Neppl C et al (2003) Patient safety leadership WalkRounds. Jt Comm J Qual Saf 29:16–26

    PubMed  Google Scholar 

  5. Shah AN, Frush KS, Luo X et al (2003) Effect of an intervention standardization system on pediatric dosing and equipment size determination: a crossover trial involving simulated resuscitation events. Arch Pediatr Adolesc Med 157:2299–2236

    Google Scholar 

  6. Morgan N, Luo X, Fortner C et al (2006) Opportunities for performance improvement in relation to medication administration during pediatric stabilization. Qual Saf Health Care 15:179–183

    Article  PubMed  CAS  Google Scholar 

  7. The Just Culture Community. Moderated by Outcome Engineering. Available via www.justculture.org Cited 9 Feb 2008

  8. Sentinel Event Statistics. Joint Commission on the Accreditation of Healthcare Organizations. April 2006. Available via http://www.jointcommission.org/SentinelEvents/Statistics. Cited 9 Feb 2008

  9. Baker DP, Gustafson S, Beaubien J et al (2005) Literature Review. Medical teamwork and patient safety: the evidence-based relation. Publication No. 05–0053, Agency for Healthcare Research and Quality. Available via http//www.ahrq.gov/qual/medteam. Cited 9 Feb 2008

  10. Leonard M, Graham S, Taggart B (2004) The human factor: effective teamwork and communication in patient safety. In: Leonard M, Frankel A, Simmonds T et al (eds) Achieving Safe and Reliable Healthcare Strategies and Solutions. Health Administration Press, Chicago, IL, pp 37–64

    Google Scholar 

  11. TeamSTEPPS™: Strategies and Tools to Enhance Performance and Patient Safety. November 2007. Agency for Healthcare Research and Quality, Rockville, MD. Available via http://www.ahrq.gov/qual/teamstepps/ Cited 9 Feb 2008

  12. Building the future for patient safety: developing consumer champions. A workshop and resource guide. Consumers for Patient Safety, and the Agency for Healthcare Research and Quality. Chicago, IL

  13. Dana Farber Patient Advisory Council. Available via http://www.dana-farber.org/pat/pfac/ Cited 4 Feb 2008

  14. Bates DW, Leape LL, Cullen DJ et al (1998) Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 280:1311–1316

    Article  PubMed  CAS  Google Scholar 

  15. Han YY, Carcillo JA, Venkataraman ST et al (2005) Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 116:1506–1512

    Article  PubMed  Google Scholar 

  16. Kilbridge PM, Campbell UC, Cozart HB et al (2006) Automated surveillance for adverse drug events at a community hospital and an academic medical center. J Am Med Inform Assoc 13:372–377

    Article  PubMed  Google Scholar 

  17. McDonald KM, Romano PS (2002) Measures of patient safety based on hospital administrative data. The patient safety indicators. Publication no. 02–0038. Agency for Healthcare Research and Quality, Rockville, MD

    Google Scholar 

  18. Thomas EJ, Sexton JB, Helmreich RL (2004) Translating teamwork behaviors from aviation to healthcare: development of behavioral markers for neonatal resuscitation. Qual Saf Health Care 13(suppl 1):1157–1164

    Google Scholar 

  19. Sorra JS, Nieva VF (2004) Hospital Survey on Patient Safety Culture. AHRQ Publication No. 04–0041. Agency for Healthcare Research and Quality, Rockville, MD

    Google Scholar 

  20. Frankel A, Gardner R, Maynard L et al (2007) Using the communication and teamwork skills (CATS) assessment to measure health care team performance. Jt Comm J Qual Saf 33:549–558

    Google Scholar 

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Correspondence to Karen S. Frush.

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Dr. Frush has no relevant financial relationship or potential conflicts of interest related to the material to be presented.

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Frush, K.S. Fundamentals of a patient safety program. Pediatr Radiol 38 (Suppl 4), 685–689 (2008). https://doi.org/10.1007/s00247-008-0882-1

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  • DOI: https://doi.org/10.1007/s00247-008-0882-1

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