Patient Safety Blueprint
The Patient Safety Blueprint is a valuable and vital resource for a patient safety officer or safety leaders dedicated to and focused on patient safety. Created in collaboration with AdventHealth Clinical Patient Safety and current safety leaders throughout the organization, this resource outlines core competencies, provides best practice resources, and presents practical tools for top focus areas in patient safety at AdventHealth. This playbook offers a guide to navigate the realm of safety through collaboration, continuous improvement, and fostering a culture where safety is paramount.
Safety Culture Survey
o Serve as Safety Culture Survey Champion.
o Refer to Safety Culture Survey SharePoint for playbook, timeline information, and additional resources.
o Support pre-survey preparations and actively liaise between facility leadership and AdventHealth Corporate Clinical Patient Safety team.
o Assist with post-survey process, timelines, effective result utilization, debriefing, and action plan expectations.
Safety Huddles
o Collaborate with Executive team to set expectations for a facility-wide leadership safety huddle; understand what information elevates an operationally based huddle to a true safety focused leadership huddle including high risk safety activity.
o Encourage all departments to facilitate a once per shift huddle if not already occurring; be available as a resource to department leaders to enhance the huddles following HRO Huddle Guidelines.
o Facilitate safety huddles or briefings among teams. When appropriate, train other leaders to appropriately debrief specific situations (i.e.: falls debriefs, response debriefs to Workplace Violence situations).
Rounding for Safety
o Engage in various rounding methods focused on team and patient safety with closed-loop communication.
o Relational Rounding with team members is essential in identifying team culture strengths and areas of concern.
o Connect with Executive team to support Executive WalkRounds to Walk the Talk and encourage participation.
o Develop strategy for documentation of findings and follow-up.
o Establish leadership rounds cadence including weekends and nightshift.
o Support teams participating in Patient Experience rounds and leverage patient safety learnings
Medication Safety
o Medication Safety Practices
o Medication Reconciliation
o High-Alert Medication Protocols
o Dual Verification Procedures
o Use of Approved Medication Dispensing and Storage Processes
o Sterile Compounding USP797/ Hazardous Handling USP800
o AdventHealth Pharmacy Services
o Clinical Pharmacy Resources
o Medication Safety Technologies:
o CPOE
o Barcode Scanning Compliance
o Smart Pumps
▪ Smart Pump Library Compliance
▪ Medication Safety & Pump Library Resources
o Automated Dispensing Cabinet Override Compliance
o Medication Monitoring:
o Antimicrobial stewardship programs in collaboration with Pharmacy, Infection Prevention and Laboratory
▪ The Joint Commission E-dition
▪ Antimicrobial Stewardship
o Adverse Drug Event
o Diversion Prevention
Infection Control & Emergency Preparedness
o Collaborate with Quality and Infection Prevention team on surveillance of healthcare associated infections, antibiotic-resistant organisms, and outbreaks.
o Monitor hand hygiene compliance and appropriate Personal Protective Equipment (PPE).
o Assess and engage with executive leaders on the Emergency Preparedness Plan.
Process Improvement
o Support process improvement projects using appropriate methodology and PI tools (ie: PDSA, Lean Six Sigma).
o Encourage multidisciplinary collaboration on solutions to patient safety concerns, such as unit-based councils.
o Access the High Reliability Organization (HRO) team for assistance and utilize the Performance Improvement for LENS Board resources, if applicable.
o AdventHealth internally offered trainings: Lean Six Sigma (Green/Black Belt), PROSCI Change Management Certification
Training & Knowledge Integration
o Establish and manage ongoing training programs and educational initiatives.
o Educate on patient safety protocols.
o Update leaders on safety guidelines.
o AdventHealth internally offered trainings: Patient Safety Academy, RCA2
Organizational Compliance
o Ensure compliance with regulatory prerequisites
o Conduct mock surveys, assessments, and audits.
o Document and report compliance with national and state standards.
o Collaborate with your facility Executive team on initiatives within Clinical Excellence Review.
o Leapfrog A
o Premiere Mortality
o CMS 5 Star
Risk Mitigation and earning Systems
o Review and analyze reported risk events with Quality, Safety, & Risk.
o Assess trends and vulnerabilities using dashboards and learning systems.
o Focus on near-miss events, share learnings.
o Monitor Patient Safety Indicators (PSIs).
o Utilize modalities (LENS Boards) for safety concerns and guide appropriate reporting methods.
Patient Safety Organization (PSO)
o AdventHealth Patient Safety Organization –utilize as a resource to better understand the privilege and confidentiality afforded to Patient Safety Work Product (PSWP).
o Understand PSO Program Commons Terms and Acronyms: PSO, PSWP, PSES, Patient Safety Activity/Components.
o Complete recommended PSO Immersion Training and understand who else needs to receive the information.
o Utilize PSO Services to support your safety priorities and goals.
o Connect with local PSO Liaison with any questions.
Recognition Program for Patient Safety
o Implement and manage a “great catch” recognition program.
o Support psychological safety and foster a culture of “speaking up” when there are concerns about safety and quality of care.
o Share lessons learned across entities for a proactive approach of risk mitigation.
o Celebrate milestones for harm prevention and/or safety teamwork improvements.
o Promote and coordinate local celebrations of National Patient Safety Week/Day.
High Reliability Framework Integration
o Incorporate High Reliability Organization (HRO) principles into hospital policies and procedures
o ALN | Onboarding to High Reliability & Unit Culture
o Create and update patient safety policies, procedures, and protocols as applicable.
o Collaborate with leaders to establish strong safety cultures.
o Provide guidance and resources to unit-specific challenges
o Recognize and celebrate department-specific safety achievements
o Advocate for Just Culture.
o Participate in HRO Academy to serve as facility High Reliability Facilitator.
o Unit Culture - Huddle-Framework-Principles Crosswalk
dditional Resources
o AdventHealth Library
o Clinical Quality & Safety - Home (sharepoint.com)
References
Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and Effective Care. White Paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017.
Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture Version 2.0. (n.d.).
https://www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-v2-resourcelist.pdf
Institute for Safe Medication Practices (ISMP). ISMP Targeted Medication Safety Best Practices for Hospitals. ISMP; 2022. https://www.ismp.org/guidelines/best-practices-hospitals.
Lee, S. E., & Dahinten, V. S. (2021). Psychological safety as a mediator of the relationship between inclusive leadership and nurse voice behaviors and error reporting. Journal of Nursing Scholarship, 53(6), 737-745.
National Steering Committee for Patient Safety (NSC). Safer together: a national action plan to advance patient safety. Institute for Healthcare Improvement (IHI). 2020.
https://www.ihi.org/Engage/Initiatives/National-Steering-Committee-Patient-Safety/Pages/NationalAction-Plan-to-Advance-Patient-Safety.asp
Ongoing Patient Safety Challenges. ECRI, 2023.
https://www.ecri.org/components/HRC/Pages/Ongoing_Patient_Safety_Challenges_Top10.aspx
Sculli, Gary L. MSN, ATP; Pendley-Louis, Robin DrPH, MPH, CPH; Neily, Julia RN, MS, MPH; Anderson, Timothy M. RN, MS; Isaacks, David B. MA; Knowles, Regina MEd, BSN, RN; Young-Xu, Yinong ScD, MA, MS; Gunnar, William MD, JD. A High-Reliability Organization Framework for Health Care: A Multiyear Implementation Strategy and Associated Outcomes. Journal of Patient Safety 18(1): p 64-70, January 2022. | DOI: 10.1097/PTS.0000000000000788
Top 10 patient safety concerns 2023 special report. ECRI. (n.d.). https://www.ecri.org/top-10-patientsafety-concerns-2023-special-report
