Blueprint For Patient Safety

ARTICLE IN PRESS
Pediatr Clin N Am j (2006) j–j
Blueprint for Patient Safety

Polly Stevens, RRT, MHSca,*, Anne Matlow, MDb,c,
Ronald M. Laxer, MDc,d
a
Quality and Risk Management, The Hospital for Sick Children, Toronto, ON, Canada
b
Infection Prevention & Control Programme, The Hospital for Sick Children,
Toronto, ON, Canada
c
University of Toronto, Toronto, ON, Canada
d
The Hospital for Sick Children, Toronto, ON, Canada
The most compelling cause for health care professionals is to ensure the
safety of their patientsdand when the patients are children, the stakes are
high indeed. Much has been written about, and licensing and accrediting
agencies have prescribed, the practices and programs that could or should
be implemented in health care organizations to achieve safer care. This ar-
ticle outlines the plan, or blueprint, for a comprehensive patient safety pro-
gram adopted at The Hospital for Sick Children, and which the authors
suggest can be adapted for other institutions. This blueprint attempts to
knit together the sometimes disparate elements of a patient safety program
into a cohesive, practical, and easily understood whole. The blueprint starts
with a graphic that depicts the basic objectives of patient safety and clarifies
the sometimes misunderstood relationship between patient safety and more
traditional quality-improvement activities. A second schematic outlines the
key elements of the plan, including the concepts of continuous learning and
the encompassing role of leadership. Finally, the 10 components of the plan
and specific elements that could fall under each component are described.
Getting the program started

In customizing their own patient safety plans, organizations must, as
a first step, conduct an internal assessment to identify those practices that
already are working well and those elements that will make implementation
of the plan more challenging. Box 1 outlines some of the factors that could
affect implementation of a patient safety plan.
* Corresponding author. The Hospital for Sick Children, 555 University Avenue,
Toronto, ON M5G 1X8, Canada.
E-mail address: polly.stevens@sickkids.ca (P. Stevens).
0031-3955/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.pcl.2006.09.013 pediatric.theclinics.com
Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
ARTICLE IN PRESS
2 STEVENS et al
Box 1. Factors affecting implementation of a patient safety plan

Facilitating factors
A ‘‘burning platform,’’ such as occurs after an actual or potential
serious adverse event
Strong leadership support
Good quality-improvement culture and infrastructure
Committed teams
Compelling mission to improve the health of children
Challenging factors
Fear of reprisal
Strong program and professional autonomy
Inconsistent follow-up of ideas and initiatives
Fragmented clinical information systems
Relatively young workforce
Key patient safety concepts

The blueprint is based on several key patient safety concepts. These
include
Organizational learningdsuccessful organizations pay particular atten-
tion to their processes for scanning their internal and external environ-
ments for useful information and for using this information to change
practices in incremental and transformational ways [1].
The ‘‘systems’’ approachda recognition that there are many layers that
influence outcomes in a health care organization, including regulatory
bodies, management structures and decisions, and team, individual,
and patient factors [2,3].
‘‘Just’’ cultureda framework for the fair treatment of staff involved in
incidents that does not espouse a totally blame-free approach; rather,
it recognizes the limitations of human performance while not tolerating
intentional acts of harm [4].
Complexity theory and complex adaptive systemsdsystems, such as
health care, are predictably unpredictable and certain approaches,
such as standard operating procedures, are more or less effective de-
pending on the degree of uncertainty and agreement in a given situa-
tion [5].
High reliability organizationsdsome organizations in high-risk industries
are able to achieve lower than expected accident rates. These organiza-
tions are highly sensitive to front-line operations, deal explicitly with
safety, are preoccupied with failure (that is, they extract maximum learn-
ing from actual and potential adverse events), are reluctant to simplify
interpretations, and defer to local expertise in times of crisis [6].

ARTICLE IN PRESS
BLUEPRINT FOR PATIENT SAFETY 3
Hindsight biasdlimitations of human cognition may lead to incorrect as-

sumptions after an adverse event, in particular that staff involved in the
event should have been able to predict and thereby avert the outcome.
As a result, adverse event analysis must attempt to recreate the situa-
tion from the perspective of front-end staff and determine which fac-
tors and distractions kept staff from preventing adverse events [7].
Human factors engineeringdthe performance of human beings is influ-
enced greatly by their environment and in particular by the design of
systems and technology. Well-designed equipment, for instance, can
lead to lower rates of error [8].
‘‘Extreme’’ honesty and humanistic risk managementda strategy that in-
cludes proactive investigation, full disclosure and apology, and fair
compensation to patients (and their families) who have been injured
as a result of medical error [9].
The concept of quality versus patient safety

In some organizations, the understanding of patient safety principles
may be limited even though a culture of quality improvement may be
well established. In these instances, staff may require some insights into
the relationship between quality improvement and patient safety, such as
those depicted in Fig. 1. The left side of the graphic represents 10 children
who have come to the hospital for treatment, each one experiencing a spe-
cific level of care ranging from low to high quality. The middle section
depicts the focus of quality improvement, which is to raise the ceiling so
that higher levels of care can be achieved. The far right section depicts
the focus of patient safety, which is to raise the floor so that fewer patients
experience poor levels of care or are harmed. Ultimately, quality improve-
ment and patient safety work together to improve the overall quality of
care provided.
Quality Improvement
(raising the ceiling)
High
QUALITY OF
CARE
Patient Safety
(raising the floor)
Low
Fig. 1. Relationship between quality improvement and patient safety (see text for explanation).

ARTICLE IN PRESS
4 STEVENS et al
Program model and components

Fig. 2 presents a simple model that describes the major elements of the
Blueprint for Patient Safety. It highlights the need to scan the internal
and external environments for relevant safety information, for applying
that learning to identifying vulnerabilities and opportunities for improve-
ment, for making appropriate changes, and for re-evaluating these changes
continually in an ongoing feedback loop. The model also emphasizes the en-
compassing and facilitating role of leadership, culture, and communication.
Ten components of the patient safety blueprint

The blueprint is divided into 10 components:
1. Leadership and culture
2. External surveillance
3. Internal surveillance
4. Management of critical occurrences
5. Risk assessment and prioritization of initiatives
6. Staff education
7. Policies, procedures, and guidelines
8. Partnering with patients and families
9. Evaluation and research
10. Program coordination and oversight
Each of these components is discussed briefly, focusing on specific ele-
ments that could be incorporated into a comprehensive patient safety
plan. Table 1 outlines the complete list of components and elements.
Leadership and culture

The first component, leadership and culture, represents the most critical
aspect of the plan. Culture matters because organizations are made up of
people who have their own values and beliefs. Organization leaders can pro-
mote a patient safety culture by articulating shared values, modeling
Leadership, culture, coordination
External
Info.
ID unsafe Evaluate and Communicate

Make
practices & audit and report
changes
vulnerabilities
Internal
Info.
Leadership, culture, coordination
Fig. 2. Patient safety plandconceptual framework.

ARTICLE IN PRESS
Table 1
Components of the blueprint and associated activities
Blueprint
component Specific elements
1. Leadership Patient safety included in an organization’s strategic
and culture and operating plans
Patient safety addressed at time of hire and is an
element in performance reviews
Leadership safety rounds and follow-up processes
Culture surveys and follow-up processes
Decisions based on safety rather than short-term fiscal priorities
2. External Comprehensive inventory of external sources of safety
surveillance information and responsibilities assigned to monitor
these sources on an ongoing basis
Process (ideally electronic) to record and ensure
follow-up of relevant information
3. Internal Comprehensive, easy-to-use incident reporting system
surveillance allowing for anonymous reporting and capturing of
qualitative and quantitative details about an event
Process for sharing learning from reports
Retrospective or real-time incident, or trigger reporting systems
Comprehensive M&M process with hospital-wide oversight and review
Routine surveillance of patient safety indicators
Annual proactive system-wide safety assessment
4. Management of Defined policy, procedure, and process for managing
critical events critical events using a systems approach
Defined policy for disclosure of adverse of events
Process (ideally electronic) for ensuring follow-up of
recommendations arising from reviews
Process for sharing learning from reviews internally and externally
5. Risk assessment Process for managing and prioritizing safety initiatives
and prioritization Tracking system to report the status of safety initiatives
of initiatives that are under way
6. Staff education Many informal and formal mechanisms for educating
staff on patient safety and for sharing lessons learned across an
organization (including newsletters, rounds, and orientation)
Staff engaged in formal external collaborations and partnerships to
share patient safety learning beyond the organization
7. Policies, Systematic review of existing policies, procedures,
procedures, guidelines to ensure they are up to date
and guidelines Process and oversight for development of new documents
to ensure they are relevant, evidenced-based,
hospital-wide focused, and stakeholder inclusive
System (ideally electronic) to ensure most up-to-date
version of documents are available to staff at all times
Ongoing process (ideally electronic) to ensure that
documents are reviewed on a regular basis
Regular audits of key policies to ensure compliance
(continued on next page)

ARTICLE IN PRESS
6 STEVENS et al
Table 1 (continued )
Blueprint
component Specific elements
8. Partnering with Formal involvement of families and patients in patient safety
patients and initiatives
families Periodic consultation with children regarding patient safety concerns
and ideas for improvement
9. Evaluation and Evaluation as a mandatory component of all safety initiatives
research Patient safety research interests developed as appropriate
10. Program Designated department and medical staff to coordinate patient
coordination and safety activities across an organization, supported by allocation of
oversight financial and human resources
Clear expectations at the local level for patient safety
Senior oversight committee for patient safety
Board reporting and responsibility for patient safety
appropriate behaviors (such as teamwork and transparency), and establish-

ing expectations for staff. Leaders also can advance patient safety in how
they set goals and establish priorities, develop plans, and allocate resources.
Organizations committed to patient safety articulate this as an essential or-
ganizational goal and then translate this goal into specific actions [10]. Spe-
cific activities related to this component include ensuring that patient safety
is included in the strategic plan and in the annual operating plan and bud-
get; also, patient safety should be addressed at the time of hire and be part of
regular performance reviews. Leadership safety rounds, in which senior
leaders meet with staff in front-line areas to discuss safety concerns, are an-
other element that can be incorporated to enhance the culture of safety in
organizations [11]. Periodic culture surveys, whether or not they are specific
to patient safety or more general in focus, also are becoming standard tools
in evaluating and improving organizations’ safety climate. As with safety
rounds, the benefits from surveys are realized only if particular attention
is paid to ensuring appropriate follow-up of feedback obtained from staff
through these mechanisms.
On a practical level, evidence that patient safety has been entrenched
firmly in an organization’s strategy and operations could be seen in deci-
sions in which the safety of children is put ahead of other competing,
short-term (usually fiscal) priorities. An example of this is the decision to
preadmit certain high-risk children the night before surgery (versus
a more cost-effective same-day admission) as a mechanism to ensure all crit-
ical preprocedure preparations are complete.
Summary of elements included in this component:
Patient safety included in an organization’s strategic and operating
plans
Patient safety addressed at time of hire and is an element in performance
reviews

ARTICLE IN PRESS
Leadership safety rounds and follow-up processes

Culture surveys and follow-up processes
Decisions based on safety rather than short-term fiscal priorities
External surveillance
Organizational learning is defined as the capacity within organizations to
maintain or improve performance based on (their own or another’s) experi-
ence. Effective learning organizations diligently pursue an enhanced knowl-
edge base through a network of external and internal scanning and feeder
systems. When feedback shows a gap, particularly if it implies failure, these
organizations respond with experimentation and development and incre-
mental or transformational improvements. In learning organizations, long
periods of entirely positive feedback may not be viewed favorably, as fail-
ures are seen as opportunities for improvement [1].
In health care, harmful adverse events do not need to be experienced to
learn from them. By making an effort to learn from the mistakes of others,
organizations have the opportunity to improve care without the human toll
associated with actual events. Recently, there has been an explosion of infor-
mation on patient safety. Literature, conferences, agencies, and networks
abound that promote a greater understanding of medical error and commu-
nicate best practices in patient safety. With the amount of information avail-
able to them, organizations run the risk of either spending too much time in
reviewing marginal material or failing to note information that could benefit
them. As a result, a coordinated system is required for reviewing external
information, evaluating its usefulness, and ensuring the appropriate imple-
mentation of recognized safe practices.
As a start, organizations should create an inventory of external data
sources and assign specific services or staff members the task of monitoring
these sources routinely for relevant safety information. For example, bio-
medical engineering staff can be charged with reviewing and following up
on device recalls and alerts; pharmacy staff with medication-related notices,
alerts, and best practices; transfusion services with blood-related alerts and
practices; quality staff with changes to accreditation and licensing; and so
forth. Taking this a step further, organizations also can consider the devel-
opment of a database, ideally linked to staff e-mail systems, to enter and
track responses to relevant alerts and other important information.
Comprehensive inventory of external sources of safety information and
responsibilities assigned to monitor these sources on an ongoing basis
Process (ideally electronic) to record and ensure follow-up of relevant
information
Internal surveillance
Improvements in patient safety require a comprehensive understanding of
what is going on in an organization, including the incidence of error, harm,

ARTICLE IN PRESS
8 STEVENS et al
and potential harm. Studies show that incidents are vastly underreported by
staff; however, reporting rates can be improved when (1) staff feel safe in re-
porting events, (2) reports are easy to complete, and (3) staff receive feedback
about positive changes made as a result of this information [12].
Organizations should look to incorporating reporting systems that cover
a wide range of patient, staff, and visitor events. Ideally, they should be elec-
tronic and linked to staff e-mail systems to facilitate timely analysis, internal
dissemination, and follow-up. The ability to enter reports anonymously also
should be considered, as should the ability for staff to record the ‘‘story’’ be-
hind the event, not just predetermined categories or codes. Emphasis also
should be placed on reporting near misses and close calls, as this allows
for learning without the challenges associated with actual events. Of critical
importance, leaders must be educated to ensure that safety reports are not
used as a tool to review individual staff performance. Most organizations
also will be challenged to provide input back to staff as to what they have
done with, and what improvements have resulted from, the information ob-
tained through safety reports. This could be achieved at the local level
though staff meetings or debriefings and at the organizational level through
regular communication tools, such as newsletters and websites.
Organizations also may consider implementing another type of incident
reporting system that does not rely on staff members to report an event.
These systems are based on a defined set of conditions, or triggers, which
have been shown to be linked to an adverse event (for example, the admin-
istration of naloxone may indicate that an overdose of an opioid may have
occurred). These triggers may be picked up concurrently, if an organiza-
tion’s health information system is sufficiently advanced, or through retro-
spective chart audit. Trigger systems may be more likely to detect adverse
drug events (ADEs). In a study of ADEs, a trigger tool was found to detect
approximately 50 times more ADEs than traditional methods, such as re-
porting or other methods [13]. In addition to incident reporting systems,
there are many other internal sources of safety information, including mor-
bidity and mortality (M&M) rounds. M&M rounds are a well-recognized
mechanism for ensuring deaths and significant morbidity are reviewed by
those who have the most relevant clinical expertise and the most knowledge
of patients [14]. Organizations should consider developing systems to sup-
port multidisciplinary M&M reviews at each clinical division, for incorpo-
rating hospital-wide oversight to ensure these reviews are performed, and
to detect any significant trends and issues that cross the system.
Another mechanism for safety learning is the routine collection and anal-
ysis of an appropriate range of safety indicators. Many of these indicators
relate to information from incident reports (eg, rate of patient falls and med-
ication incidents associated with highly toxic medications) and infection pre-
vention and control measures (eg, bloodstream infections associated with
central lines, ventilator-associated pneumonia, and postoperative infection
rates) [15]. Accurately coded health records data also may be a useful source

ARTICLE IN PRESS
of safety information (eg, unexpected returns to an operating room, emer-

gency department, or critical care unit). Wherever possible, targets and
benchmarks should be established for each indicator.
Finally, using all available sources of safety information, at least annu-
ally, a system-wide safety assessment should be performed with input
from stakeholders. The Joint Commission on Accreditation of Healthcare
Organizations in the United States states, ‘‘proactive identification and
management of potential risks to patient safety has the obvious advantage
of preventing adverse occurrences, rather than simply reacting when they
occur. This approach also avoids the barriers to understanding created by
hindsight bias and the fear of disclosure, embarrassment, blame, and pun-
ishment that can arise in the wake of an actual event’’ [16].
Comprehensive, easy-to-use incident reporting system allowing for
anonymous reporting and capturing of qualitative and quantitative de-
tails about events.
Process for sharing learning from reports
Retrospective or real-time incident, or trigger, reporting systems
Comprehensive M&M process with hospital-wide oversight and
review
Routine surveillance of patient safety indicators
Annual proactive system-wide safety assessment
Management of critical events
The recognition of critical events is an important component of internal
surveillance; however, given the effect these events can have on an organiza-
tion’s culture, the management of critical events is given special attention in
the blueprint.
Unfortunately, despite the best of intentions, mistakes happen that result
in significant harm to patients. It is important that senior leadership, med-
ical staff, and employees handle these events with courage and honesty and
with a commitment to finding and improving system issues and to sharing
these lessons with others. How a crisis is managed can affect the patient
safety culture in organizations for years to come. A focus on identifying
and improving underlying system issues, and on openness with patients
and families, do a great deal to advance the patient safety agenda, signaling
to staff that leadership truly have moved beyond a blame-and-shame
culture.
All organizations should have a policy and procedure for managing crit-
ical events, including expectations for immediately addressing the needs of
patients, families, and staff involved in events. It also should articulate pro-
cesses for investigating events, developing recommendations for improve-
ment, and ensuring appropriate follow-up of changes. The London
protocol provides a helpful model for those looking to set up effective pro-
cesses for managing critical events [17].

ARTICLE IN PRESS
10 STEVENS et al
A companion policy on disclosure also should be in place highlighting pa-

tients’ and families’ rights to be informed after an adverse event and provid-
ing direction for staff in managing these discussions.
A primary focus of critical occurrence reviews is the development of rec-
ommendations for improving a system and for preventing the recurrence of
similar events. One of the challenges organizations will face as they conduct
comprehensive reviews is ensuring that recommendations resulting from the
reviews are implemented and have the intended effect. This is easier to do at
the beginning; however, as more and more reviews are conducted, the num-
ber of recommendations accumulates quickly and follow-up becomes a sig-
nificant challenge. Organizations should consider the development of an
electronic database to facilitate tracking of reviews and recommendations.
Finally, organizations should take every available opportunity to share
the learning and improvements resulting from reviews internally and exter-
nally (as privacy constraints enable).
Defined policy, procedure, and process for managing critical events us-
ing a systems analysis
Defined policy for disclosure of adverse events
Process (ideally electronic) for ensuring follow-up of recommendations
arising from reviews
Process for sharing learning from reviews internally and externally
Risk assessment and prioritization of initiatives
Robust internal and external surveillance networks will result in a large
number of potential issues brought to the attention of leaders. Unfortu-
nately, given constraints on human and financial resources, it would be un-
likely that all these important issues could be addressed at the same time.
Organizations will require a thoughtful and transparent process for prioritiz-
ing patient safety initiatives. Such a process is described in Fig. 3. Internal
and external information is used to identify possible gaps or areas for im-
provement. Local issues are directed to local leaders for resolution. Issues
that cross the organization undergo a risk assessment to identifying processes
and practices with either a high severity or high probability for patient harm.
Those deemed to be of higher risk are assessed further for fit with an organi-
zation’s strategies and goals, the availability of resources, and other external
imperatives (such as mandatory accreditation standards). If sufficient infor-
mation is available, a formal multidisciplinary improvement project or initia-
tive then may be commissioned. If more information is required, then an
audit may be commissioned (the results of which then would feed back
into the prioritization framework). Individual organizations would have to
determine how many initiatives they realistically could have under way at
any one time. This would depend on internal resources and expertise and
the size of each initiative. As new higher-risk issues arise, previously identi-
fied projects may have to be delayed or suspended temporarily.

ARTICLE IN PRESS
External
Internal information
information Safety database & best
& best practices
practices
Analysis, trending,
sense making,
Assign
reporting
responsibility,
action and report
Yes No
Yes
FYI or action & Local program or
report department Quick fix?
specific issue? No
Risk assessment
Project 1 Frequency
Process Severity, etc.
Team selection
Project coordinator
Executive sponsor
Others
Scope Develop list of
Expected resources potential issues,
Stakeholders audits & projects
Deliverables
Milestones & timelines
Lit. review & pre-testing
Changes & interventions Priority-setting
Tool-kit (e.g., PDSA / based on:
rapid-cycle improvement Organizational
idealized design) strategy
Progress & final reports
Resources
Evaluation & publication
External
imperatives
Clinical Internal
Audit 1 consultation
Project 2
Clinical
Audit 2
Project 3 (etc.)
Commission
audits & projects
Clinical
Audit 3 (etc.)
Fig. 3. Model for risk assessment and prioritization of patient safety initiatives.
Depending on the number of initiatives, a project tracking system (which

provides concise status reports on the initiatives) may need to be developed
to ensure appropriate leadership oversight.
Process for managing and prioritizing safety initiatives
Tracking system to report the status of safety initiatives that are under
way
Staff education
Health care workers need to know their role in providing safe care to pa-
tients and requiring education and training on general patient safety topics
(eg, human factors, disclosing adverse events to patients and families,

ARTICLE IN PRESS
12 STEVENS et al
teamwork, and communication), area-specific safety initiatives, and lessons

learned elsewhere in the hospital and beyond.
In addition to informal mechanisms, such as one-on-one and team sup-
port, several formal opportunities for staff to learn about patient safety,
to share lessons learned, and to celebrate successes should be implemented.
Examples of patient safety learning opportunities are
Key lessons in patient safety at orientation
Regular news items in a hospital’s newsletter
Publication of a regular patient safety–focused newsletter
Regular patient safety education rounds
Ad hoc area-specific rounds and meetings
Patient safety web site and resources
Regular meetings of local quality representatives featuring hospital-
wide initiatives and team successes and lessons learned
Many informal and formal mechanisms for educating staff on patient
safety and for sharing lessons learned across an organization (including
newsletters, rounds, and orientation)
Staff engaged in formal external collaborations and partnerships to
share patient safety learning beyond the organization
Policies, procedures, and guidelines

Research into complex adaptive systems (such as hospitals) shows that
having a common purpose and easily understood rules can lead to innova-
tive system behavior [18]. Policies, procedures, and guidelines are common
instruments used to translate patient safety insights into practice. Good pro-
cedures and guidelines can provide clarity in situations where there is expert
agreement about the appropriate course of action, and they can provide use-
ful learning tools for less experienced staff. These tools, however, need to be
kept up to date and must be accessible to staff.
Organizations should ensure that there are clear standards for policy crea-
tion and that approval processes are articulated clearly. A top-to-bottom re-
view of existing policies may be required to ensure that all policies are up to
date, are relevant, and do not conflict with one another. In large organizations
with many work units, ensuring that all staff members have the most up-to-
date version of documents is a particular challenge best addressed through
the implementation of an on-line document management system and the elim-
ination of paper copies. Managing the review and reapproval cycle also is
a challenge best managed with a database linked to the staff e-mail system.
Tight controls should be in place to make sure that any new documents
have supporting evidence, that documents are developed with a hospital-
wide perspective in mind, that appropriate stakeholders are consulted,
and that communication and evaluation plans are developed. Organizations

ARTICLE IN PRESS
also should develop a process to select and carry out compliance audits of
high-risk policies, procedures, and guidelines.
Systematic review of existing policies, procedures, guidelines to ensure
they are up to date.
Process and oversight for development of new documents to ensure they
are relevant, evidenced based, hospital-wide focused, and stakeholder
inclusive.
System (ideally electronic) to ensure most up-to-date version of docu-
ments are available to staff at all times
Ongoing process (ideally electronic) to ensure that documents are re-
viewed on a regular basis
Regular audits of key policies to ensure compliance
Partnering with patients and families
Patients and families play an important role in ensuring safe care. They
represent an important line of defense and should be encouraged to question
organizational routine, procedures, and processes and whenever something
does not look or seem ‘‘right’’ [19].
Consideration should be given to the creation of a patient safety working
group or committee with significant representation from families with the
objectives of raising awareness among health care professionals on the
role of parents in patient safety, empowering family members to speak
up, and providing education to families about patient safety. If organiza-
tions have a children’s council, then it should be consulted on a regular basis
regarding safety concerns and ideas for making a hospital safer.
Formal involvement of families and patients in patient safety initiatives
Periodic consultation with children regarding patient safety concerns
and ideas for improvement
Evaluation and research
Evaluation should be a mandatory component of all new safety projects,
including appropriate plans for dissemination and publication of results.
Patient safety, particularly in the pediatric environment, represents a rel-
atively new area of study. Consideration should be given to the development
of a patient safety research interest group to promote the interchange of
ideas and collaboration among hospital staff.
Evaluation as a mandatory component of all safety initiatives
Patient safety research interests developed as appropriate
Program coordination and oversight
No one argues that ‘‘safety is everybody’s business’’; however, most expe-
rienced administrators know that in order for critical operations and

ARTICLE IN PRESS
14 STEVENS et al
systems to be maintained, there needs to be dedicated process-owners. In

most organizations, coordination of patient safety activities falls under the
auspices of a quality/risk/safety department. Consideration also should be
given to appointing a senior physician leader to patient safety programs
to enhance coordination and communication of patient safety throughout
an organization.
Direction also must be given to local leaders and quality committees to
ensure their expectations for managing safety issues and improvements in
their areas are clear. This can be facilitated through regular reporting struc-
tures and mandatory program elements. At a hospital-wide level, there
should be a senior level committee to provide oversight for the patient safety
program and initiatives to ensure alignment with hospital strategies and ob-
jectives. This committee should in turn report to an organization’s board of
directors.
Designated department and medical staff to coordinate patient safety
activities across an organization, supported by allocation of financial
and human resources.
Clear expectations at the local level for patient safety
Senior oversight committee for patient safety
Board reporting and responsibility for patient safety
Summary
The Blueprint for Patient Safety provides a solid foundation for building
an organization’s patient safety program. The 10 components serve as
a comprehensive framework for improving a safety culture and for provid-
ing staff with insights into the many dimensions of patient safety.
An annual review of the progress made in each area is critical in deter-
mining whether or not an institutional patient safety agenda is being met
or whether or not the goals and directions need to be modified.
References
[1] Nevis EC, DiBella AJ, Gould JM. Understanding organizations as learning systems. Sloan
Manage Rev 1995;36:73–85.
[2] Reason JT. Managing the risks of organizational accidents. Aldershof (UK): Ashgate; 1997.
[3] Reason JT. Human error: models and management. BMJ 2000;320:768–70.
[4] Marx D. Patient safety and the ‘‘just culture’’: a primer for health care executives. New York:
Columbia University; 2001.
[5] Zimmerman B, Lindberg C, Plesk P. Edgeware: insights from complexity science for health
care leaders. Irving (TX): VHA; 1998.
[6] Weick KE, Sutcliffe KM. Managing the unexpected: assuring high performance in an age of
complexity. San Francisco (CA): Jossey-Bass; 2001.
[7] Cook RI, Woods DD. Operating at the sharp end: the complexity of human error. In: Bogner
MS, editor. Human error in medicine. Hillsdale (NJ): Lawrence Erlbaum Associates; 1994.
p. 255–310.

ARTICLE IN PRESS
[8] Gosbee J, Lin L. The role of human factors engineering in medical device and medical system
errors. In: Vincent C, editor. Clinical risk management: enhancing patient safety. 2nd ed.
London: BMJ Books; 2001.
[9] Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann
Intern Med 1999;131963–7.
[10] Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system.
Washington, DC: National Academy Press; 2000.
[11] Frankel A, Graydon- Baker E, Neppl C. Patient safety leadership walkrounds. Jt Comm
J Qual Saf 2003;29:17–26.
[12] Gosbee JW. Reporting systems for safety knowledge. In: Zippere LA, Cushman S, editors.
Lessons in patient safety. Chicago: National Patient Safety Foundation; 2001.
[13] Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: a practical methodol-
ogy for measuring medication related harm. Qual Saf Health Care 2003;12:194–200.
[14] Friedman JN, Pinard MS, Laxer RM. The morbidity and mortality conference in university-
affiliated pediatric departments in Canada. J Pediatr 2005;146:1–2.
[15] The Agency for Healthcare Research and Quality (AHRQ). The pediatric quality indicators:
measures of pediatric health care quality based on hospital administrative data. February
2006. Available at: http://www.qualityindicators.ahrq.gov/pdi_download.htm. Accessed
October 20, 2006.
[16] Joint Commission on Accreditation of Healthcare Organizations. Patient safety standards.
Oakbrook Terrace (IL: Joint Commission on Accreditation of Healthcare Organizations);
2000.
[17] Taylor-Adams S, Vincent C. Systems analysis of clinical incidents: the London protocol.
London: Clinical Safety Research Unit, Imperial College; 2004.
[18] Committee on Quality Health Care in America, Institute of Medicine. Crossing the quality
chasm: a new health system for the 21st century. Washington, DC: National Academy Press;
2001.
[19] Agency for Healthcare Research and Quality. Five steps to safer health care. Rockville
(MD): Agency for Healthcare Research and Quality; 2001.


Blueprint For Patient Safety

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Blueprint For Patient Safety

Uploaded by

Copyright:

Available Formats

ARTICLE IN PRESS

Pediatr Clin N Am j (2006) j–j

Blueprint for Patient Safety

Getting the program started

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

Box 1. Factors affecting implementation of a patient safety plan

Key patient safety concepts

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

BLUEPRINT FOR PATIENT SAFETY 3

Hindsight biasdlimitations of human cognition may lead to incorrect as-

The concept of quality versus patient safety

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

Program model and components

Ten components of the patient safety blueprint

Leadership and culture

Leadership, culture, coordination

ID unsafe Evaluate and Communicate

Leadership, culture, coordination

Fig. 2. Patient safety plandconceptual framework.

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

BLUEPRINT FOR PATIENT SAFETY 5

(continued on next page)

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

appropriate behaviors (such as teamwork and transparency), and establish-

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

BLUEPRINT FOR PATIENT SAFETY 7

 Leadership safety rounds and follow-up processes

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

BLUEPRINT FOR PATIENT SAFETY 9

of safety information (eg, unexpected returns to an operating room, emer-

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

A companion policy on disclosure also should be in place highlighting pa-

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

BLUEPRINT FOR PATIENT SAFETY 11

Depending on the number of initiatives, a project tracking system (which

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

teamwork, and communication), area-speciﬁc safety initiatives, and lessons

Policies, procedures, and guidelines

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

BLUEPRINT FOR PATIENT SAFETY 13

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

systems to be maintained, there needs to be dedicated process-owners. In

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

BLUEPRINT FOR PATIENT SAFETY 15

Downloaded from ClinicalKey.com at Universitas Gadjah Mada August 30, 2016.

You might also like

Leadership safety rounds and follow-up processes