Children’s Hospitals and Clinics

Ila M. Harris Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN Leslie Helou Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN Brian J. Isetts Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN Steven B. Karch Consultant Pathologist/Toxicologist, Berkeley, CA Richard L. Kingston SafetyCall International, PLLC, Principal and Senior Clinical Toxicologist, Bloomington, MN Katie L. Meyers Pharmacy Department, Children s Hospitals and Clinics of Minnesota, Minneapolis, MN... 

One of the hrst steps taken in connection with the comprehensive patient safety agenda at Children s Hospitals and Clinics, Minneapolis/St. Paul, Minnesota, was to invite randomly selected employees, residents, students, physicians, and families to participate in focus groups. The following case study illustrates how focus groups were used to gather information and to create awareness of patient safety. 

Source E. Knox and ]. Morath, Simple Rules (Minneapolis Children s Hospitals and Clinics, 1999). 

Paper forms should have limited, fixed fields and significant space for the descriptive story of what happened. For example, a Web-based reporting form that is secure and password-protected was designed at Children s Hospitals and Clinics, Minneapolis/St. Paul, Minnesota. The form asks just five questions ... 

The following case study involves a redesign of the reporting system at Children s Hospitals and Clinics, Miimeapolis/St. Paul, Minnesota. It describes how a system was built with the knowledge of the ASRS and the work of the Veterans Administration s National Center for Patient Safety. 

Like the ASRS form, the Children s Hospitals and Clinics safety learning report asks the reporter an open-ended question about the incident "What happened " There is ample room for a written response. The reporter then clicks through to a new screen and is prompted with additional questions ... 

As stories of lessons learned, published in internal publications throughout Children s Hospitals and Clinics... 

As the Children s Hospitals and Clinics organization moves forward in its evolution toward a safety culture, plans for the following actions have been developed to glean further knowledge from data ... 

Source Key Performance Indicator Report, Children s Hospitals and Clinics of Minnesota, October 2002. 

For doctors, nurse practitioners, and other health care professionals who prescribe medications, writing a prescription easily becomes as automatic as driving a car. Unfortunately, it can be just as dangerous. Mark Thomas, director of pharmacy services at Children s Hospitals and Clinics, Minneapolis/St. Paul, Minnesota, is responsible for helping prescribers improve safety by using "safe prescribing."... 

Morath, J., Malone, G., and Anderson, A. The Patient Safety Learning Packet. Minneapolis Children s Hospitals and Clinics of Minnesota, 1999a. 

In an effort to improve the safety of our patients at Children s Hospitals and Clinics the Medication Safety Team is providing this direct feedback to you, the individual piescribers/transcribeis of medication orders. Historical evidence supports that certain unsafe order writing practices or habits have led to very serious consequences, while tbe inclusion of certain information can help prevent errors. 

Edmondson, A. C., Roberto, M. A. and Tucker, A. Children s Hospitals and Clinics. Boston Harvard Business School Press, 2001. HBS Case Study N9-302-050. 

Edmondson, A.C., Roberto, M.A., and Tucker, A. 2001. Children s Hospital and Clinics. HBS Case No. 302 050. Harvard Business School Publishing, Boston. 

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