Patient safety officer

Designate a patient safety officer and create an internal reporting system. 

The lOM recommends that healthcare should establish a comprehensive patient safety function overseen/operated by trained personnel in a culture of safety. Organizations should designate a dedicated patient safety officer. An effective patient safety officer promotes action through the training... 

Joint Commission Resources and Institute for Healthcare Improvement. The Essential Guide for Patient Safety Officers. JCR Publishing, 2009. 

Thus, although it may be safe to rely on your patient safety officer for tactical systems improvements, it is rarely successful to rely on him or her to lead culture change. So, given the complexity of the healthcare world, how does one build a culture that values safety ... 

Significant deficiencies in the security and control of samples have been well documented. " " In fact, it has been estimated that just over half of samples actually reach patients. Samples may be used by prescribers and staff, or they may be diverted. Personal use of drug samples by physicians and other healthcare providers raises ethical concerns and is not without risk." Limaye and Paauw described three medical residents who self-prescribed antimicrobials and were subsequently diagnosed with Clostridium difficile infection." Tong and Lien reported self-medication with samples and distribution of samples to nonphysicians by almost 60% of pharmaceutical representatives surveyed at a Canadian family practice office. A contributing factor to some of these issues is that institutional or facility sample policy and procedures are often absent, or compliance is poor. One institution found only 10% compliance when the inventory of samples was compared with the required written documentation. Even after an educational program in which the policy was explained to the house staff, a second audit found only 26% compliance. " Poor compliance with policy and procedure may jeopardize patient safety, as well as put the institution at risk for JCAHO recommendations or Board of Pharmacy penalties. 

HIT is finding an increasing role in healthcare dehvery and no longer is its apph-cation limited to simple order entry. Outside of medication management the evidence for HIT playing an active role in the reduction of risk is lacking and much more research is required [39]. This is hampered by no obvious or consistent benchmark by which to measure these benefits. Nevertheless, the prospect of HIT better informing care delivery makes it likely that in the near future improvements in patient safety will be achieved. The US Office of the National Coordinator for... 

US Office of the National Coordinator for Health IT. ONC Health IT safety program - progress on health IT patient safety action and surveillance plan. 2014. 

In the past the safety officer made it his duty to ensure he was notified as soon as an injured employee arrived at the hospital. He had a contact there who would page him immediately upon a patient being admitted to emergency. He would then be the first person at the hospital and would attempt to convince the medical staff that the injured person could return to the plant. If he was successful, no reportable injury was recorded and he would then report to management that only a minor injury had taken place and there was no need for concern. 

Since the publication of the Institute of Medicine report, many governments and professional organizations have released reports and official statements on patient safety. The British equivalent of the Institute of Medicine report was prepared by a group led by Professor Liam Donaldson, the UK Chief Medical Officer (Department of Health, 2000). Unlike the Institute of Medidne report, it emanated from government and was bravely authorized for release by the then Secretary of State for Health, Alan Milbum. 

Another component of the comprehensive patient safety programme has been initiated in four ICU units adopters (current and pending) include the President of the Johns Hopkins University, President of the Johns Hopkins Health System, Chief Operating Officer of the JHH and the Vice President for Hmnan Resources at the JHH This site has provided the organization with a means of disseminating project information and sharing ideas This centre reports to the CEO and university president and provides support for quality and safety improvement initiatives... 

Kristensen, A., Mainz, J. and Bartels, R 2007. Establishing a Set of Patient Safety Indicators. Safety Improvement for Patients in Europe. SlmPatlE - Work Package 4. Aarhus The ESQH-office for Quality Indicators. 

Event reporting Event reporting is important for hospitals to understand patient safety risks and enable them to take steps to prevent and mitigate harm to patients. However, the status of event reporting in the US still shows considerable nnderreporting. A 2012 report from the Office of the Inspector General found that US hospital incident reporting systems captured only an estimated 14 percent of the patient harm events experienced by Medicare beneficiaries (Department of HHS 2012). 

Kristensen, S. and Bartels, P. 2010. Use of Patient Safety Culture Instruments and Recommendations. EUNetPaS (European Union Network for Patient Safety) European Society for QuaUty in Healthcare - Office for Quality Indicators, Denmark... 

Sorra, J., Famolaro, T., Dyer, N., Smith, S., Lirr, H. and Ragart, M. 2012. Medical Office Survey on Patient Safety Culture 2012 User Comparative and Database Report (AHRQ Pub. No. 12-0052). Rockville, MD Agency for Healthcare Research and Quality. Available at http //www.ahrq.gov/qual/mosurveyl2 (last accessed on 28 April 2014). 

US Congress 2005. Patient Safety and Quality Improvement Act of2005, S. 544, enacted by the 109th Congress. Washington US Government Printing Office. 

Six months after the patient safety climate survey was conducted, a written survey on action, taken in response to the results, was conducted among quality officers and senior management in the hospital s various specialist units and institutes. This revealed an uneven picture. In 22 specialist units and institutes survey results were found to corroborate the need to target known areas of action and ongoing projects and were used as a basis for discussion and reflectiom... 

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