Designing and Implementing a Comprehensive Quality and Patient Safety Management Model

Patient Safety Reporting Systems: Sustained Quality Improvement Using a Multidisciplinary Team and “Good Catch” Awards

“…22 Our process incorporated these four elements within the setting of a multidisciplinary team that reviewed local events on a frequent basis. 10 At the end of this process, the “Good Catch” award publicly recognized clinicians for their efforts in reporting hazards and leading initiatives to improve patient safety. Importantly, the “Good Catch” award was only awarded if the precipitating event/hazard underwent our process of multidisciplinary team review, involved of a range of stakeholders, resulted in the development of an initiative to mitigate the original hazard.…”

“…10 All individuals who are familiar with the event context should participate in interpreting the hazard (i.e., those who can tease out the various human and organizational factors involved). 11 A diverse team can offer a comprehensive knowledge base.…”

“…The WPCST meets weekly to address perioperative issues related to safety, quality, efficiency, teamwork, and development of new surgical services. 10 …”

“…Weighted priority score calculations using a tool developed by the team are used to rank hazards so that the team can most efficiently use limited resources. 10 At the conclusion of the meeting, specific action items and a timetable are agreed upon. Follow-up dates are set to discuss progress at the next WPCST weekly meeting.…”

Q-Tip: From Local Quality Improvement to National Drug Recall

“…Analysis of the event by a multidisciplinary perioperative quality improvement team of physicians, nurses, risk managers, and human factors engineers 4 revealed that, one week earlier, a certified registered nurse anesthetist (CRNA) had notified the team that cefazolin and vecuronium vials with a similar appearance were adjacent to one another in the automated medication dispenser. Investigation found that the current supply of vecuronium and cefazolin had look-alike packaging and that the vecuronium labeling was noncompliant with United States Pharmacopeia (USP) standards because “Paralyzing Agent” was not on the cap and the ferrule.…”