Cropper Douglas P, Harb Nidal H, Said Patricia A, Lemke Jon H, Shammas Nicolas W
Genesis Health System, Davenport, IA.
Midwest Cardiovascular Research Foundation, Davenport, IA.
J Healthc Risk Manag. 2018 Apr;37(4):17-24. doi: 10.1002/jhrm.21319. Epub 2018 Mar 31.
We hypothesize that implementation of a safety program based on high reliability organization principles will reduce serious safety events (SSE).
The safety program focused on 7 essential elements: (a) safety rounding, (b) safety oversight teams, (c) safety huddles, (d) safety coaches, (e) good catches/safety heroes, (f) safety education, and (g) red rule. An educational curriculum was implemented focusing on changing high-risk behaviors and implementing critical safety policies. All unusual occurrences were captured in the Midas system and investigated by risk specialists, the safety officer, and the chief medical officer. A multidepartmental committee evaluated these events, and a root cause analysis (RCA) was performed. Events were tabulated and serious safety event (SSE) recorded and plotted over time. Safety success stories (SSSs) were also evaluated over time.
A steady drop in SSEs was seen over 9 years. Also a rise in SSSs was evident, reflecting on staff engagement in the program. The parallel change in SSEs, SSSs, and the implementation of various safety interventions highly suggest that the program was successful in achieving its goals.
A safety program based on high-reliability organization principles and made a core value of the institution can have a significant positive impact on reducing SSEs.
我们假设基于高可靠性组织原则实施安全计划将减少严重安全事件（SSE）。
安全计划侧重于7个基本要素：（a）安全巡查，（b）安全监督小组，（c）安全碰头会，（d）安全教练，（e）良好捕捉/安全英雄，（f）安全教育，以及（g）红色规则。实施了一项教育课程，重点是改变高风险行为和实施关键安全政策。所有异常事件均在迈达斯系统中记录，并由风险专家、安全官员和首席医疗官进行调查。一个多部门委员会对这些事件进行评估，并进行根本原因分析（RCA）。将事件制成表格，记录严重安全事件（SSE）并随时间绘制图表。随着时间的推移，还对安全成功案例（SSS）进行了评估。
在9年时间里，严重安全事件稳步下降。安全成功案例也明显增加，这反映了员工对该计划的参与度。严重安全事件、安全成功案例以及各种安全干预措施的实施情况的平行变化强烈表明该计划成功实现了其目标。
基于高可靠性组织原则并成为机构核心价值观的安全计划可对减少严重安全事件产生重大积极影响。
