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Free Content Implementing a Hospitalwide Patient Safety Program for Cultural Change

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Background: After focus groups revealed that staff perceived a punitive culture, Missouri Baptist Medical Center (MBMC) embarked on a comprehensive patient safety program, which was initially directed at creating a just culture of patient safety.

Interventions: A series of structures, processes, and initiatives were introduced to change the attitudes of management and staff toward human error, to communicate broadly with staff and the community, and to provide feedback on leadership's responses to specific events. All events reported were tracked continuously and recorded each month on a spreadsheet.

Results: Total medical events reported by staff increased significantly (p < .001) from 35 to 132 per 1,000 patient days. Reports to the hotline alone increased significantly (p < .001) from 3 to 23 per 1,000 patient days, and the proportion of callers who left their names increased significantly (p < .001) from 30% to 61%. Survey results from staff showed a small but significant increase in awareness of patient safety and in comfort with reporting.

Conclusion: The implementation of a carefully planned and orchestrated series of interventions designed to improve a hospital's culture of patient safety can, if led by senior hospital executives, lead to a substantial, profound, and lasting increase in error reporting and improvement in employee perceptions of the organization's safety culture.

Document Type: Research Article

Publication date: December 1, 2004

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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