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Using Four-Phased Unit-Based Patient Safety Walkrounds to Uncover Correctable System Flaws

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Background: A unit-based Patient Safety Leadership WalkroundsTM (PSWR) model was deployed in six medical/surgical units at The Children's Hospital of Philadelphia to identify patient safety issues in the clinical microsystem. Specific objectives of PSWR were to (1) provide a forum for frontline staff to freely report and discuss patient safety problems with unit local leaders, (2) improve teamwork and communication within and across units, and (3) develop a supportive environment in which staff and leaders brainstorm on potential solutions.

Methods: Baseline data collection and discussion with leaders and staff from the pilot units were used to create a standard set of safety tools and questions. Through multiple Plan-Do-Study-Act cycles, safety tools and questions were refined, while the process of walkrounds in each of the six pilot units was customized.

Results: Leaders in all six pilot units indicated that PSWR helped them to uncover previously unidentified safety concerns. Top-impact areas included nurse-medical team relationship, work-flow flaws, equipment defects, staff education, and medication safety. The project engaged 149 individuals across all disciplines, including 33 physicians, and entailed 34 PSWR in its first year. Information from these pilot units initiated safety changes that spread across multiple units, with identification of hospital-wide quality and patient safety issues.

Conclusions: For participating units, the PSWR process is a situational awareness tool that helps management periodically assess new or unresolved vulnerabilities that may affect safety and care quality on the unit. Unit-based PSWR help identify safety concerns at the microsystem level while improving communication about safety events across units and to hospital leaders in the macrosystem.

Document Type: Research Article

Publication date: September 1, 2013

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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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