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“People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.” –Donald Norman, PhD, Apple Fellow, in The Design of Everyday Things

Take time and be ready before something goes wrong

Know in advance how your organization will respond when a patient is harmed by care. Decide now what first steps you’ll take, how you will communicate with colleagues and patients about the event, and how to get to the bottom of what happened.

Have a plan in place for collecting information about adverse events

Consider adjusting your current reporting process or design one:

  • How does a patient or staff member report a problem?
  • Who collects the information? How is it collected and recorded?
  • What information is collected/recorded?
Have a checklist or flowchart outlining what to do with that information
  • Who needs to be involved in an immediate conversation?
  • Who is responsible for making immediate changes (e.g. removing faulty equipment, stopping administration of incorrectly-labeled medications)? Keep track of staff members and others involved in the event who can later provide more in-depth information for analysis.
  • Who will gather a team to analyze the event? Conducting a root cause analysis of an adverse event or near miss is a critical step in preventing it from happening again.
  • How will you report the event externally, if applicable? Many serious events involving patient harm must be disclosed to state and/or federal health authorities.
  • Who will communicate with patients and/or their families as well as to colleagues when a serious adverse event has occurred? Who will support staff members following the event?
Learn from patients and families
  • Patients and families can provide valuable insight into a harm event and often appreciate the opportunity to give feedback.
  • Discuss how your office will provide a forum for patients and families to express concerns and how you will let them know that you are open to their comments.
  • Be sure this process includes:
    • a way for patients to speak to a safety contact person,
    • a way to document the concern, and
    • a way to make sure there is follow up.
  • Consider more regular mechanisms for patient input, such as suggestion boxes, surveys, or a dedicated patient liaison.
Begin safety efforts proactively
  • Communicate with every staff member about expectations for how to report concerns and what should be reported, including close calls, adverse events, and problem areas.
  • Similarly, communicate about expectations for how staff will respond when something goes wrong. Do not wait until something goes wrong to prepare.
  • Consider including patient representatives on planning activities or safety initiatives.
  • Use existing huddles or organize specific ones on safety to gather staff feedback and concerns.