Patient Safety Leadership WalkRounds™ at Partners HealthCare: Learning from Implementation

Frankel, Allan; Grillo, Sarah Pratt; Baker, Erin; Huber, Camilla Neppl; Abookire, Susan A.; Grenham, Marianne; Console, Pam; O'Quinn, M. Caroline; Thibault, George E.; Gandhi, Tejal K.

doi:10.1016/s1553-7250(05)31056-7

Cited by 52 publications

(64 citation statements)

References 16 publications

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“…(3,(7)(8)(9) We found that 234 of the 321 (72.9%) issues raised during the walkabouts were not identified through other conventional methods of error detection such as incident reporting, morbidity and mortality rounds. Actions taken for certain issues identified during the walkabouts are highlighted in Table II.…”

Section: R E Su Lt Smentioning

confidence: 89%

“…This differs from most hospitals in the West, where walkabouts are conducted on a weekly basis. (3,(8)(9)(10) We opine that monthly walkabouts are optimal for TTSH as this gives the healthcare staff on the ground adequate time to reflect on the possible safety issues in their respective units, so that these issues can be raised during the walkabout. This will allow a more fruitful discussion between the participants and the core team.…”

Section: Discussionmentioning

confidence: 99%

“…(7) To date, there have been several reports regarding the implementation of PSLWA in several hospitals in the West. (3,(8)(9)(10) However, a perspective from Asia is lacking. We therefore reviewed the PSLWA programme in Tan Tock Seng Hospital (TTSH), Singapore, and evaluated the effectiveness of the programme in improving the hospital's patient safety culture.…”

Section: Introductionmentioning

confidence: 99%

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Evaluation of the Patient Safety Leadership Walkabout programme of a hospital in Singapore

Lim

2014

smedj

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RESUlTSA total of 321 patient safety issues were identified during the study period. Of these, 308 (96.0%) issues were resolved as of November 2012. Among the various categories of issues raised, issues related to work environment were the most common (45.2%). Of all the issues raised during the walkabouts, 72.9% were not identified through other conventional methods of error detection. With respect to the hospital's patient safety culture, 94.8% of the participants reported an increased awareness in patient safety and 90.2% expressed comfort in openly and honestly discussing patient safety issues.CONClUSION PSLWA serves as a good tool to uncover latent errors before actual harm reaches the patient. If properly implemented, it is an effective method for engaging leadership, identifying patient safety issues, and supporting a culture of patient safety in the hospital setting.

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Section: R E Su Lt Smentioning

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Evaluation of the Patient Safety Leadership Walkabout programme of a hospital in Singapore

Lim

2014

smedj

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“…The ED safety team of one hospital decided to implement patient safety rounds as a way to engage frontline staff and seek their knowledge and expertise and suggestions for ways to improve patient and medication safety, consistent with previous success with this methodology in identifying safety issues, and supporting a culture of safety [48]. The ED safety rounds involve ED administration including physician and nursing leadership, executives from Quality and Patient Safety, frontline staff, and residents during their administration rotation.…”

Section: Safety Roundsmentioning

confidence: 99%

Toxicology in the Service of Patient and Medication Safety: a Selected Glance at Past and Present Innovations

Smith

Farmer

2015

J. Med. Toxicol.

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Medical and medication errors remain definite threats to patients in US health care. Medical toxicologists frequently encounter patients either harmed by or at risk for harm from adverse drug events, including medication errors and inadvertent exposures. An historical perspective, as viewed through the lens of specific disciplines, can be useful to trace systemic responses to safety threats. Early efforts to address anesthesia perioperative risks and recent actions in medicine, surgery, and obstetrics to introduce checklists, communication tools, and systems approaches are reviewed. Patient safety concepts can be utilized and disseminated by toxicologists to improve medication safety and drive innovative approaches to confront patient harm. Various approaches include simulation of high-risk scenarios which might predispose to medication error, assembling multidisciplinary groups of health care providers to review events and implement mitigation strategies, and proactive patient safety rounds in clinical areas to allow frontline staff to voice concerns and introduce solutions for administration, evaluation, and implementation. We review selected lessons from the past and current innovations to achieve safe medication practice.

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“…508,509 However, the development and maintenance of appropriate organisational feedback mechanisms is known to be a significant challenge. 510,511 Patient stories…”

Section: Walkroundsmentioning

confidence: 99%

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Herepath

Kitchener

Waring

2015

Health Serv Deliv Res

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BackgroundHospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.ObjectivesThis study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.DesignWe used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.SettingWelsh Government and NHS Wales.ParticipantsInterviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.Main outcome measuresIdentification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.ResultsAn innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.ConclusionsHeightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Patient Safety Leadership WalkRounds™ at Partners HealthCare: Learning from Implementation

Cited by 52 publications

References 16 publications

Evaluation of the Patient Safety Leadership Walkabout programme of a hospital in Singapore

Evaluation of the Patient Safety Leadership Walkabout programme of a hospital in Singapore

Toxicology in the Service of Patient and Medication Safety: a Selected Glance at Past and Present Innovations

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

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