By Anne M. Meiring

To build a true culture of safety, every employee must accept responsibility for keeping every patient safe from harm. You can help reduce risk to patients by “speaking up” and completing a Patient Safety Report about anything that has caused or could cause injury to a patient. To err is human, but each of us must be accountable for reporting occurrences so the healthcare team is aware of potential risk to our patients. Reporting is made simple by going to the ShandsConnect Portal, linking under “Special SHC Resources” to “Patient Safety Reports” (PSRs).

What happens when a PSR is entered?

The Shands at UF Quality Department, senior management, and your managers and supervisors are made aware of patient events that harmed or could have harmed a patient. Analysis is done to identify trends, system issues and areas for improvement. We may form a Performance Improvement Team to address identified trends. When there is an adverse patient event, we often use a Root Cause Analysis to examine all factors that may have contributed to the outcome.

What benefit do we get from the PSR system?

Our PSR system allows managers and supervisors to analyze data to better understand patterns and determine what improvements are needed to decrease patient safety risks hospital-wide. Proactive reporting of situations that may have caused harm to one patient may help us prevent actual harm to the  next patient. If you would like to follow up on actions taken to improve care after an event that you reported, please call the Quality Department at 352-265-0002.

Our data

A review of our data from July through September 2010 shows a high level of participation in reporting patient safety events at Shands. Most fell within these three categories:

1) Blood-/specimen-related — These are commonly “wrong specimen in the tube” or specimens received unlabeled by the lab. The most frequent cause was that staff did not correctly identify the patient and label at the bedside.

Action: Staff are invited to voluntarily present ideas to improve compliance at special forums.

2) Treatment-, test- or procedure-related — These events relate to variances in performing a test, administering treatment or conducting a procedure. The most frequent cause was a breakdown in communication or staff not following best practices.

Action: Best practices are continually being implemented.

3) Medication errors — Two common causes are staff interruptions/distractions and not following best practices.

Action: The Medication Safety Committee is addressing issues, with staff involvement.