CHILDRENS HOSPITAL AND CLINIC

Group 2 Ashim Gupta 13PGHR08

Emani Swati 13PGHR15

Gagandeep Singh 13PGHR16 Himanshu Goel 13PGHR17 Megha Mahesh 13PGHR23 Shashank Rai 13PGHR44

Introduction
Patient Safety Initiative
Presenting Medical Accident Data

Blameless Reporting

Conducting Focus Groups

Confidential Communicati on New Patient Safety Report

Determining the underlying causes Use of appropriate language

Formulating the Strategic Plan

Assessment of Patient Safety Initiative

Increase in openness in communication regarding medical errors Enhanced understanding of safety, identification of risks and reporting them without fear of blame Increase in creative ways to ensure safety Taking the feedback of family of the patients gave an understanding of the real time problems E: S: Safety A:Access F: Financial Experiential Well defined strategy formulated:

Assessment of Blameless Reporting

Increase in responses by the employees Enhancement of the knowledge pool of the possible medical errors and hence avoiding them Change in traditional way of reporting the errors Easy access to discover and eliminate breakdowns in hospitals systems and processes Identification of the root cause Difficult to reprimand the person responsible for the error

Barriers faced by Julie Morath

Scepticism towards the relevance of Medical Data Getting Approval for Focus Group with families
Legal Risk
Increased discussions of incidents amongst the employees Persuaded the employees that the discussions would help in improving patient safety

Obtained the approval of the Board An opportunity provided to the parents to talk about their personal experiences and to offer suggestions Parental Good Catch Logs Took the guidance of the legal advisors

Measuring Effectiveness

Arrangement of resources to implement the measures successfully

Leadership

Full time chair of PSSC hired

Julie Moraths Leadership

Focussed on Patient Safety Successful in creating a culture to improve upon the hospital systems and processes Enhanced the involvement of the employees: Blameless Reporting System, Language used Increased transparency: New disclosure policy Strategy made and implemented successfully Proper Delegation of Responsibility to Dr. Eric Knox