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January 10, 2005 Volume 14 No. 1

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Steps Toward Establishing a Culture of Patient Safety

Duke University Health System (DUHS) is following a defined path to help move the institution into a culture where patient safety is a top priority for every employee:

â€¢ Measure: Since 2002, DUHS has conducted an annual patient safety survey during Patient Safety Week in November. Results from the 2004 survey should be available later this spring.

â€¢ Educate Staff: The Dec. 16 seminar was the first in a series of educational programs planned for Duke University Hospital physicians and staff.

â€¢ Identify Safety Concerns: In addition to the new program at DUH, Health System employees can identify clinical quality and patient safety concerns/events through the Voluntary Reporting System (https://vrs.duhs.duke.edu) and through Leadership Rounds. Duke has also recently started using an electronic surveillance system to monitor electronic records for possible adverse drug events.

â€¢ Assign Executives: The Duke Hospital initiative assigns a senior executive to each Clinical Service Unit specifically to participate in clinical quality and patient safety performance improvement efforts.

â€¢ Identify Priority Areas: Prioritizing of patient safety and clinical quality issues will take place at the local level, the CSU level, at the hospital level through the Performance Improvement Oversight Committee, and at the level of the Patient Safety Committee of the DUHS Board.

â€¢ Implement Improvements: Having interdisciplinary patient safety and clinical quality teams existing in each CSU and unit will make implementing improvements easier.

â€¢ Share Stories: Already the DUH Accreditation and Patient Safety Office shares lessons learned and best practices through its bimonthly publication of Patient Safety and Clinical Quality News (available online at www.accred.dukehospital.org). As hospital teams implement new best practices, these will also be shared.

â€¢ Re-measure Culture: DUHS will continue to evaluate faculty and staff perceptions of patient safety every year. In addition, certain questions on the Press Ganey Patient Satisfaction survey provide valuable feedback on patientsâ€™ perceptions of patient safety practices throughout the Duke University Health System.

Who Are the Patient Safety Advocates in Your Unit?
Duke Hospital Creates Teams for Patient Safety

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It is easy to get lost in the figures about patient safety. How can anyone comprehend numbers such as 100,000 preventable deaths in a year?

Joe Graedon helped more than 200 leaders from Duke Hospital understand the human story behind medical errors when he shared his understanding of how a series of seemingly unrelated, small glitches turned his motherâ€™s heart procedure from success to tragedy. Graedon, who serves on the Duke University Health Systemâ€™s Board Committee on Patient Safety and Quality Assurance, shared his perspectives as part of a day-long patient safety seminar in December to launch Duke Hospitalâ€™s new interdisciplinary, integrated patient safety and clinical quality program.

Creating a Web of Patient Safety Advocates
â€œNone of us come to work intending to harm a patient,â€ Bill Fulkerson, M.D., chief executive officer for Duke Hospital, told the Hospital leaders. â€œBut medical care is complex, and complex systems do fail. Organizations that are successful in establishing a culture of safety recognize the ubiquity of risk â€" that it can happen anywhere, to anyone. These organizations view the recognition of errors as opportunities for learning how to further reduce risk. One of our aims with this program is to reach through all levels of the organization to get information about patient safety and clinical quality. We know from experience that when we go to front-line staff and ask â€˜where is the next mistake likely to happen?â€™ we get very revealing answers. We know that a clinical quality and patient safety initiative has to be run by the people actually providing the care.â€

The goal of the new program is to create teams of front-line employees from each patient care area who will serve as watchdogs and resources for clinical quality and patient safety issues and initiatives. â€œIn some units, there may already be groups that can serve this role,â€ says Gail Shulby, director of Accreditation and Regulatory Affairs for DUHS and Patient Safety Officer for Duke University Hospital. â€œIn that case, it is a matter of making sure that patient safety and clinical quality issues are continuously present on the agenda. In other areas, there may be interdisciplinary groups that can serve in this role if certain people are added, or the unit may decide to create a completely new team. However the team is set up, the membership will be such that it can fulfill its responsibilities.â€

These front-line, local teams will be supported by core teams at the Clinical Service Unit (CSU) or departmental level. To ensure that information is flowing from front-lines to senior levels and back again and to provide a visible commitment to patient safety and clinical quality, each core team will also have an executive sponsor assigned to it.

CSU medical directors and administrative leaders will also begin regularly scheduled patient safety Executive Walkrounds. â€œThese Walkrounds are a proven method for engaging frontline care providers in discussions about patient safety and clinical quality,â€ says Shulby.

The December meeting of administrative and clinical leaders was the first step in creating a unified baseline of knowledge about patient safety at Duke Hospital. In early 2005, the rest of the hospital patient care staff and physicians will participate in training on patient safety and clinical quality. Later in the year, all hospital staff will participate in similar training to assist everyone in recognizing their unique role in patient safety and clinical quality.

For more information about the Duke Hospital Patient Safety and Clinical Quality Initiative, visit the Accreditation and Patient Safety Web site at www.accred.dukehospital.org or call 681-8176. This site includes presentations from the December meeting.