Patient Safety 6.

Learning Boards
• One tool that can be

used.
• Utilized to display safety

concerns identified by
staff and practitioners.
Learning Boards
• Through staff meetings,
leadership WalkRounds and
other such activities, the
prioritization of the safety
concerns is determined and
the appropriate individuals
assigned to each initiative.
Learning Boards
• Frequently used with the CUSP program
Comprehensive Unit-based Safety Program

(CUSP)
• a part of the AHRQ's Healthcare-

Associated Infections Program that
focuses on generating evidence for the
development and implementation of
interventions to reduce healthcare
associated infections.
Learning Boards
• Benefits:
1. Promotes visibility of
specific concerns and
what is being done to
resolve the
concerns/issues.
Learning Boards
• Benefits:
2. Transparency
demonstrates to the staff
and others that their input
is critical to having a well-
functioning patient safety
program.
Learning Boards
• Benefits:
3. Valuable for the staff

and others to report the
safety concerns without
fear of reprisal.‫االنتقام‬
Physician Participation
1. The development and
implementation of the
patient safety
program.
2. Identified patient
safety initiatives such as
hand hygiene, time out,
and so forth.
3. Designing programs to
reduce risk in clinical
aspects of patient care.

4. Identification, Evaluation
and Reporting:
- Any medical error to Risk

Management.
- Potential risk in clinical

aspects of patient care/safety.
5. Teams to correct
problems in the clinical
aspects of patient care and
patient safety identified
through performance
improvement and risk
management.
Responsibilities of Patient Safety Officer and
Quality Professional in a patient safety program
Responsibilities of patient safety officer in
a patient safety program
1. Coordinate leadership
activities, patient safety
education and activities that
support the patient safety
program like performance
measurement, event reporting,
the flow of information and data
analysis.
2. Integrate activities of PS
teams (the PSO is not always
the team leader); Integrate
organizational functions
concerning safety. Works
closely with Risk Manager and
Quality Manager.
3. Review of policies and
procedures.
4. Communication and education
of patient safety information to
promote organizational
understanding of safe practices.

5. Promote a non-punitive
error-reporting system.
6. Ensure that proactive
and reactive activities are
conducted.
Role of the Quality Professional
1. Often designated as the Patient
Safety Officer.
2. Be able to help facilitate and
coordinate, all of the leadership and
program activities described above.
3. Be knowledgeable of all related
safety activities.
4. Facilitate integration with
related organization functions,
including infection
surveillance, control, and
prevention and environmental
safety processes.
5. Minimize duplication of
effort in policy/procedure
development, education of
staff and patients, data
collection and aggregation,
and communications.
6. Coordinate event / occurrence
reporting, the flow of information
and performance measurement
and prioritize available patient
safety data and information for
analysis, reporting, and decision
making.
7. Ensure that reactive activities,
such as root cause analysis
(RCA), and proactive activities,
such as failure mode and effects
analysis (FMEA), are conducted
timely, efficiently, and
effectively.
Patient Safety Tools & Resources
• Can be utilized to help build and
maintain a Patient Safety
program.
Josie King Foundation.
• One very effective resource is a
video of Josie's mother telling
the story of Josie's care and her
subsequent death. Educate
healthcare workers.
Institute for Healthcare Improvement -
Open School
• Open School online course.
• Provide education to healthcare professionals
interested in quality, patient safety, and other
related topics.
TeamSTEPPS
• Developed by AHRQ to increase evidence

based teamwork system to improve
patient safety, communication and
teamwork skills among health care
professionals and make quality
improvements.
Comprehensive Unit-based Safety
Program (CUSP)
• A part of the AHRQ's Healthcare-
Associated Infections Program that focuses
on generating evidence for the
development and implementation of
interventions to reduce healthcare
associated infections.
• The CUSP is a combination of teamwork,
communications, and techniques to
improve safety culture, and uses a checklist
of proven practices.
Agency for Healthcare Research and
Quality - Patient Safety Net.
• The Agency for Healthcare Research
and Quality (AHRQ) has developed a
section on its website that focuses
solely on patient safety information.
The web-based resource is called the
Patient Safety Net (PSNet) and
contains the latest news and resources
on patient safety.
Crew Resource Management
• In CRM, cognitive skills are the mental

processes used for gaining and
maintaining situational awareness, for
solving problems and for making
decisions.
• Interpersonal skills are considered the

communication and behavioral activities
associated with teamwork.
Cognitive factors
• These factors serve to modulate
performance. These factors involve
cognitive functions like attention,
memory, and reasoning‫تفكير‬/‫استنتاج‬
• Cognitive factors are internal to each

person and serve to modulate
behavior and behavioral responses
to external stimuli like stress.
• CRM is a team training program for
the optimum use of all available
human factor.
• Safety, efficiency, and morale are

considered to be the three primary
outcomes of effective crew
management.
• It is used primarily for improving
aviation safety. CRM focuses on
interpersonal communication,
leadership, and decision making in
the cockpit ‫مقصورة الطيار‬, which were
identified as the most common
factors leading to errors.
Centers for Medicare and
Medicaid - Partnership for
Patients: Better Care, Lower
Costs
• It is a public-private
partnership of hospitals to
make healthcare safer, more
reliable and less costly.
The Joint Commission - Sentinel
Event Alerts, and Quick Safety
Issues.
• Anyone can subscribe to receive

the Sentinel Event Alerts via email
when a new alert is issued. They
are free to all whether or not the
organization is accredited by TJC.
The Joint Commission Center for Transforming
Healthcare
• works with leading hospitals and health
systems using a systematic approach, to
analyze care breakdowns, discover
underlying causes, and develop targeted
solutions to complex problems. The results
of its initiatives are available to Joint
Commission accredited organizations. The
ultimate goal is to consistently provide
quality healthcare in high reliable
organizations.
Institute for Safe Medication Practices
• Provides a voluntary national error
reporting program and is also a
Patient Safety Organization (PSO) in
order to learn about the causes of
medication and vaccine errors.
• It has five medication safety

newsletters for healthcare
practitioners and consumers.
The Veterans ‫قدامى‬
‫المحاربين‬Administration
National Center for Patent
Safety
• has made all of their
resources available to the
public: TIPS newsletter,
Patient Safety Handbook,
HFMEA, RCA
Pennsylvania Patient Safety
Authority
• Reduce and eliminate medical
errors by identifying problems
and recommending solutions.
• Assist facilities in the reduction
of medical errors.
• On their website, the PPSA
publishes Patient Safety
Advisorys ‫التحذيرات‬, news and
information.

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Learning Boards

• One tool that can be

• Utilized to display safety

Comprehensive Unit-based Safety Program

• a part of the AHRQ's Healthcare-

3. Valuable for the staff

safety initiatives such as

hand hygiene, time out,

reduce risk in clinical

aspects of patient care.

- Any medical error to Risk

- Potential risk in clinical

activities, patient safety

education and activities that

support the patient safety

program like performance

measurement, event reporting,

the flow of information and data

teams (the PSO is not always

the team leader); Integrate

concerning safety. Works

closely with Risk Manager and

4. Communication and education

of patient safety information to

understanding of safe practices.

6. Ensure that proactive

and reactive activities are

2. Be able to help facilitate and

coordinate, all of the leadership and

program activities described above.

3. Be knowledgeable of all related

related organization functions,

surveillance, control, and

prevention and environmental

staff and patients, data

collection and aggregation,

reporting, the flow of information

and performance measurement

and prioritize available patient

safety data and information for

analysis, reporting, and decision

such as root cause analysis

(RCA), and proactive activities,

such as failure mode and effects

analysis (FMEA), are conducted

timely, efficiently, and

• Open School online course.

• Provide education to healthcare professionals

interested in quality, patient safety, and other

• Developed by AHRQ to increase evidence

• In CRM, cognitive skills are the mental

• Interpersonal skills are considered the

• Cognitive factors are internal to each

• Safety, efficiency, and morale are

• Anyone can subscribe to receive

• It has five medication safety

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