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Game-Changing Guidelines: RCA2

Posted By Administration, Thursday, July 23, 2015

More than 7,000 listeners tuned in to our webcast on improving root cause analyses—a clear indication that health professionals and organizations want help with their RCA process.



By Patricia McTiernan, MS


Root cause analyses have been used in health care for a long time, but the success of these investigations has been variable across organizations and the industry. As discussed at a July 15 webcast hosted by NPSF there has been a lack of standardization in the process, failure to identify systems-level causes, and, too many times, the solutions put in place after the event are not strong enough to fix the problem that caused it. On top of that, it is not unusual for busy health professionals to fail in following up to make sure the solutions they put in place are working as intended.


More than 7,000 listeners tuned in to the webcast, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, which provided an overview of the report of the same name that NPSF released in June. The high number of attendees for this session is a clear indication that health professionals and organizations want help with their RCA process.


  Jim Bagian, MD, PE
  Doug Bonacum, CSP, CPPS  
Speakers Jim Bagian, MD, PE, and Doug Bonacum, CSP, CPPS, NPSF board members who led the panel that drafted the new guidelines, began with an explanation of the report’s name. “RCA squared” refers to the fact that there are two As: root cause analyses and actions.


Root cause analysis, said Bagian, is a misnomer, because seldom is there only one root cause. Moreover, analysis does not solve anything by itself; more important is the fact that actions need to be taken to prevent future harm.


So what do the guidelines recommend? First of all, Bagian pointed out that RCA2 was put together to provide much-needed standardization and a road map for how to conduct a successful RCA that would result in effective and sustainable action that would prevent future harm to patients. The report received endorsement by a number of organizations from across the country in recognition of its value in enabling users to achieve greater impact for improving patient safety.


The purpose of an RCA2 is to find out what happened, why it happened, and what you are going to do to prevent it from happening in the future.


Bonacum summarized what he called the game-changers of this report:

  1. Use a risk-based prioritization scheme to determine what warrants an RCA2. A risk-based approach includes weighing the severity and likelihood of an event along with the actual or potential harm is poses. Risk-based prioritization allows examination of close calls, which can be a harbinger of an event.
  2. Involve patients and families. Those directly involved in the event should be interviewed to share their perspectives of what happened, but they should not be a part of the RCA2 team. The RCA2 team should include a patient/family representative—for example, a member of the hospital’s Patient and Family Advisory Council.
  3. Use an action hierarchy. The actions taken in the wake of an event and an RCA2 are the most important component, because strong actions will prevent the event from recurring. Warnings and increased training, for example, have historically been shown to be relatively weak in preventing a recurrence, while actions such as forcing functions or a simplified process that removes unnecessary steps is more likely to yield success.
  4. Involve the organization’s leadership and board. For the process to be successful, Bonacum said, it is critical that it be embraced at all levels of the organization, including the CEO and board of directors. This would involve, for example, the allocation of resources to conduct RCAs, but also the CEO’s review and approval of all actions recommended by the RCA2 team. Actions that are not approved should be documented so that the team knows why and can create another action that will be accepted. The report includes warning signs of an ineffective RCA, to help CEOs in their review.

NPSF thanks The Doctors Company Foundation for support of the production of the report and webcast. If you have not had a chance to read the report—or listen to the webcast replay—visit the web page.


Do you think the RCA2 guidelines will help improve root cause analysis in your organization? Comment on this post below (NOTE: you must be registered and logged in to this website to comment.)




James P. Bagian, MD, PE, is the director of the Center for Health Engineering and Patient Safety at the University of Michigan.

Doug Bonacum, CSP, CPPS, is vice president for Quality, Safety, and Resource Management at Kaiser Permanente.



Tags:  med errors  RCA  root cause analysis 

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Breaking Health Care’s First Commandment

Posted By Administration, Friday, June 26, 2015
Updated: Friday, June 26, 2015

Creating communications bridges between departments is vital to avoiding breakdowns in infection protocol.

by Nanne Finis, RN, MS


The often-quoted phrase “First, Do No Harm” is not really in the modern Hippocratic Oath. But a recent study of medical errors in U.S. hospitals suggests that perhaps it should be widely adopted as the first commandment of health care.


That study estimates the true number of deaths due to preventable errors may be four times more than the 98,000 per year quoted by the Institute of Medicine in its report To Err Is Human.


A culture of safety?

Given the mission of health care institutions, the general public might be surprised to hear the rising chorus of health professionals calling for a “culture of safety” to be adopted in our nation’s hospitals. Yet a 2012 IOM study reported that one-third of all hospital patients experience some form of hospital acquired conditions (HACs), ranging from minor injuries to death.


Infection, for example, was historically considered an acceptable risk of providing care, but recent changes in reimbursement regulations mandated reductions in medical errors and penalized re-admissions and infection-related length of stay. Now a whole range of technologies is available to contain the spread of infection, from robots that blast germ-killing ultraviolet light to remote monitors that keep track of hand hygiene compliance by health care workers.


But problems persist. The Joint Commission, which accredits more than 75% of U.S. hospitals, found infection prevention and control deficiencies in about half of the hospitals it surveyed in the first half of 2014. Although one in 25 hospital patients will acquire an infection during treatment, more than a third of U.S. hospitals that responded to a recent survey reported they do not have a certified infection prevention specialist on staff.


While progress is being made, it’s clear that more needs to be done. Although handwashing is regularly touted as the best way to fight infection, handwashing studies of hospital staff repeatedly place compliance in the 30% to 40% range. Health care providers need more tools to protect workers and the general population.


Readmissions and communication breakdowns are other areas of concern. A record 2,610 hospitals are under CMS penalties for readmissions. Last year, nearly 18% of Medicare patients were readmitted within 30 days. That’s two million patients at a cost of $17 billion.


The Ebola scare in a Dallas hospital last fall raised a number of new questions about communications breakdowns, preparedness, and the priority given to patient safety in U.S. hospitals. Two nurses infected with Ebola while treating a Liberian national were successfully treated for the disease, but the outcome could have been far worse. The death of “Patient Zero” in Dallas could have happened at almost any hospital in the world. And it could happen again, as long as the potential for breakdowns in communication exists.


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The Infection Multiplier Effect

A hospital that my organization worked with reported to us that one infected hospital patient was found to have come in contact with 216 people in a single day. This was during the course of a normal day of treatment. Even if a small percentage of that group was infected, imagine how quickly things could spiral out of control, especially with a virulent strain of infection.


With that kind of potential for exposure, it’s vital that hospitals have the means to identify within minutes all of the hospital personnel who may have come in contact with a contagious patient. The same goes for medical devices and transport equipment.


Creating communications bridges between departments is vital to avoiding breakdowns in infection protocol. Most hospitals still use manual processes to distribute warnings about infected patients, including physically posting isolation status at the entrance to patient rooms. This can lead to inadvertent infection exposure among hospital employees who enter the room before the warning has been posted.

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Leaders must lead

Saying that “safety comes first” isn’t enough. What drives continuous success are accountability, transparency, and regular communication. While it is laboriously time-consuming to monitor protocols and track infectious patients, health care IT is bringing real-time operational visibility to patient safety and care delivery.

  1. Check to see how well your departments talk to each other. Manual processes, like posting isolation status at the entrance to patient rooms, are too slow for the pace of today’s hospital environment. This outdated process could lead to inadvertently infected hospital employees because they haven’t been alerted to the presence of infection in a patient or patient room.

  2. Make sure there is a single source for infection information so employees don’t have to seek out details in patient records. Make someone in the organization the point person for mobilizing key stakeholders from nursing, emergency medical services, emergency medicine, critical care, infection prevention and control, and give that person the responsibility of working with external government health departments and emergency management.

  3. If your infection control processes have been in place for years and if infection rates have been trending up, find out whether hospital leadership has explored the benefits of implementing infection-tracking technology.

  4. Finally, find out if technologies currently in place have been optimized to support infection prevention. Some systems come with embedded features that only need to be activated. Among these are Real Time Location Systems (RTLS), patient flow systems, and capacity management platforms

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What’s available now?

Current technologies can also chart the path of anyone or anything (like medical devices) that came in contact with an infected patient. Some allow infection warnings to stay with the patient as long as the condition lasts and wherever the patient travels within the hospital, providing a second line of defense against the spread of infection. Isolation status can be instantly distributed to care team members, environmental services staff and transport employees via page, mobile and desktop computer alerts. Hand washing monitoring systems can provide real-time reports on compliance, including name, time, and location enterprise-wide.


Prepare, prepare, prepare

"If an Ebola patient walks into a hospital that has a high rate of infection,” says Leah Binder, president and CEO of The Leapfrog Group, “they are going to be woefully unprepared.”


Technology is no silver bullet. Without discipline, infection control is problematic no matter what plans are in place. Getting serious about safety is the first of many steps that will need to be taken to ensure the safety of patients, hospital employees, and the public at large, given the current state of infection control.


Does your organization do an effective job of communicating about infection control and risk? Comment on this post below. (To comment, please log in. If you are not already registered on our site, please register here.)

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Nanne Finis, RN, MS, is vice president of consulting services at TeleTracking Technologies, Inc. Contact her at

Tags:  communication  infection  readmissions 

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New Breed Patient, Family Advisors Move Health Care, not Flower Pots

Posted By Administration, Thursday, May 7, 2015
Updated: Wednesday, May 6, 2015

For more than a decade, hospitals have been establishing volunteer patient and family advisory councils as useful sounding boards. Today, a small but growing number of institutions are including patients and families more broadly in shaping the delivery of care.

by Stephen Littlejohn, MA, MBA


Don’t ask Kim Blanton, one of the new breed of hospital patient and family advisors, where to put the flower pots. Politely, she will say she doesn’t care. Instead, she told last week’s National Patient Safety Foundation (NPSF) Annual Congress, “Give advisors meaningful work meeting a true need.”


For more than a decade, hospitals have been establishing volunteer patient and family advisory councils. Most function as useful sounding boards, providing feedback on brochures, commenting on building designs, adjusting form language, assisting with patient satisfaction programs, and arranging flower pots.


   From left: Beth Daley Ullem, Chrissie Blackburn,
and Kim Blanton on stage at the 17th Annual
NPSF Patient Safety Congress

Meanwhile, consistent with NPSF recommendations, a small but growing number of institutions are now including patients and families more broadly in shaping the delivery of care. These advisors sit on safety committees, assist root-cause-analysis teams, participate in clinical redesign initiatives, support quality improvement projects, and serve on governing boards.


When North Carolina’s Vidant Health asked Blanton to be an advisor five years ago, her first meeting was about end-of-life care. Since then, she has interviewed candidates for senior positions like chief medical officer and worked on reducing heart failure readmissions. As a long-time cardiac patient, Blanton brought a unique perspective to the development of a transitional program that helps patients care for themselves at home.


Advisors on Staff

Increasingly, hospitals are even hiring advisors, as University Hospitals Case Medical Center in Cleveland did when it appointed parent Chrissie Blackburn as its first principal advisor on patient and family engagement. Blackburn, who also addressed the Congress, is the creator of the ETeam® program, a communications tool for point-of-care patient and family engagement. Reporting directly to the chief executive officer, she has been piloting the program in several units and is currently developing a module for hospital-acquired infections.


In 2008, Children’s Mercy Hospital in Kansas City hired parents Sheryl Chadwick and DeeJo Miller as family centered care coordinators. Seven years later, Children’s Mercy has more than 300 advisors embedded on committees, task forces, and teams throughout the hospital.


Chadwick and Miller attribute the broad involvement of advisors to a 2012 policy change “placing patients and families at the center of decision making.” By 2014, the number of participating advisors had more than doubled.


Leading a Congress workshop, they reported a parent saying she “feels like a peer on the team.” Last year, the Caregiver Action Network ranked Children’s Mercy among the nation’s top 25 organizations for patient and family engagement best practices.


Similarly, Vidant Health is doing more than sponsoring a top-level advisory council, according to Blanton. “Advisors partner with care units on the front lines, working with staff, going to meetings, and participating in rounds.”


During the 10 years she has received care and provided advice, Blanton says she has seen progress. “It’s a whole lot better. There are 150 advisors like me, helping to make it better,” she explained. Vidant fully integrates advisors on teams and committees, engages patients, and includes advisors on root-cause-analysis teams. Last year, the health system reviewed its extensive patient engagement experience, dating from 2000, during a recorded North Carolina Network Consortium online event (see Engaging Community: Patient Advisory Councils.)

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Transparency: Engagement’s Frontier

Both Children’s Mercy and Vidant Health provide advisors with training, especially on the importance of maintaining patient confidentiality. Still, engaging so many advisors on a daily basis, from the C-Suite to the front lines, requires a strong commitment to transparency.


In fact, the level of that commitment defines patient engagement’s frontier.


Hospitals and health systems are beginning to add patient and family representatives to their boards. However, some are only doing so up to a point. One asked its patient representative to leave when discussing adverse events, according to Beth Daley Ullem, a parent who joined Blanton and Blackburn on the NPSF Congress stage.


Ullem, who works with boards on improving patient safety, said there is “such a gap in the information patients are given. There is such variability on outcomes, but patients are unable to access outcomes and safety data. To get to value based health care we need outcomes and pricing transparency.”


In fact, the most recent report of the NPSF Lucian Leape Institute, Shining a Light: Safer Health Care Through Transparency, called for “extreme honesty with patients and their families from start to finish.” The report, distributed to all Congress participants, concluded that the “current status of transparency between clinicians and patients in most organizations is less than optimal.”


Apologize, Disclose, Resolve

When failures in care result in harm, the report advises clinicians to embrace apology, disclosure, and early resolution. Presenting a successful model at the Congress was the Massachusetts Alliance for Communication and Resolution following Medical Injury. Also making progress in this area are the University of Michigan Health System and the University of Illinois Medical Center at Chicago.


Although the report recommends involvement of willing patients and family in root cause analyses of medical errors, it does acknowledge the practice merits further discussion, experimentation, and research. In fact, the practice could turn out to be controversial, judging by comments from the Michigan Health and Hospital Association Keystone Center during a Congress presentation.


The Center is coordinating an initiative among the state’s hospitals to increase patient and family engagement. Kicked off in October 2013, with a white paper, the effort now involves networking activities, leadership engagement, materials development, and a measurement process. The latter includes patient, family, or caregiver participation in root cause analysis.

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Two Decades of Progress

Still, the patient safety movement has made considerable progress on patient and family engagement since October 1996, when the NPSF debuted at the first Annenberg Center patient safety conference in Rancho Mirage, California.


The Foundation officially got under way shortly thereafter on January 1, 1997, began work on a research grant program and concluded the year by announcing a survey finding 100 million Americans had been touched by medical error as patient, family or friend. Meanwhile, the Joint Commission implemented a new “accreditation watch” program for institutions experiencing a major error or near miss.


“The initiatives were good,” Linda Golodner told USA Today, but “doctors must start treating patients with respect for real change to take place.” Then the president of the National Consumers League, Golodner added that patients would detect some problems on their own if they had more information.


Now, with more information, patients and families are doing more than detecting problems. They are part of the solution.


Are you a patient involved in advancing quality and safe care? Comment on this post below.

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Stephen Littlejohn, MA, MBA, is principal of Climb the Curve Communications, LLC, and a former NPSF Board of Directors member and Communications Committee chair. 


Tags:  PFAC  Voice of the Patient 

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Intercepting Drug Name Confusion Errors

Posted By Administration, Monday, April 27, 2015
Updated: Monday, April 27, 2015

Researchers recently presented evidence to suggest that drug name confusion may be more common than previously thought, but that use of alerts in computerized prescriber order entry systems may help prevent them.

By Patricia McTiernan, MS

The Centers for Education and Research on Therapeutics (CERT) program, sponsored by the Agency for Healthcare Research and Quality, aims to increase drug knowledge and awareness, provide clinical information to patients and medical practitioners, and improve the quality of patient care while simultaneously cutting costs. Tools for Optimizing Medication Safety (TOP-MEDS) is the theme of one of only seven CERTs nationwide, and its researchers are working on four main projects that focus on different aspects of medication safety.

In one of the most recent phases of their work, the TOP-MEDs researchers presented evidence to suggest that drug name confusion may be more common than previously thought, but that use of alerts in computerized prescriber order entry systems (CPOE) may help prevent such errors. This article summarizes their most recent findings.


Background on Drug Name Confusion

Bruce L. Lambert, PhD, principal investigator of the TOP-MEDS CERT, says prior research indicates that wrong-drug errors occur at the rate of about 1 per 1,000 prescriptions in both the inpatient and ambulatory settings. Drug name confusion—a subset of wrong-drug error—is when a clinician confuses the names of two drugs that sound alike or look alike in text.


According to Dr. Lambert, drug name confusion is thought to be the most common type of wrong-drug error, and it can be costly and devastating. For example, Fosamax (a bisphosphonate used to treat osteoporosis) can easily be confused with Flomax (an alpha blocker most commonly used to treat benign prostatic hyperplasia). Hydroxyzine (often used as a sedative) can be confused with hydralazine (a vasodilator used to treat high blood pressure).


As Dr. Lambert points out, there are few effective methods to counteract wrong-drug errors at the point of prescribing. Tall-man lettering (the use of capital letters to distinguish the unique part of the name) has produced mixed results in experiments. Bar coding can be effective at finding wrong-drug errors, but to maximize its benefit it needs to be used at every stage of the drug use process.


The TOP-MEDs team created a clinical decision support (CDS) structure by combining information about drug names, drug indications, and diagnoses in the CPOE system. They tested it in the University of Illinois Hospital and Health Sciences System, in both inpatient and clinic settings. Previous phases had shown that indication alerts can intercept wrong-patient errors (i.e., creating an order in the wrong chart). The more recent phase looked at wrong-drug errors, resulting in intercepting errors at a rate of 1.4 drug name confusion errors per 1,000 alerts.

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Background on the CDS System

Maintaining accurate problem lists in electronic medical records is required by The Joint Commission and is a requirement for meaningful use of health IT as defined by the federal government. Previous research by the TOP-MEDs team used the problem list to identify wrong-patient drug errors.


William Galanter, MD, PhD, MS, medical director of the TOP-MEDs CERT, associate chief health information officer at University of Illinois Hospital and Health System, and a practicing internist, led the development of a list of indications for a subset of drugs in the system’s formulary. The drugs chosen were those that had a relatively small number of indications (for example, metformin, beta blockers, SSRIs). Alerts were set to go off if a physician ordered a drug with an indication that did not match a problem in the patient’s problem list. The physician could then either 1) add the problem to the problem list; 2) change the order; or 3) override the alert.


The team examined more than 125,000 alerts that occurred over a six-year period. According to Dr. Galanter, they determined that an error had been intercepted if the following conditions were met: an alert triggered; the initial medication order was not completed; and the same prescriber ordered a similar-sounding medication for the same patient within five minutes. Similarity of drug names was based on standard measures, and two clinicians performed chart review to determine whether the first, uncompleted order had a plausible indication for use.


The results showed 1.4 drug name confusion errors were intercepted per 1,000 alerts. “From the literature, we had a sense that the rate of wrong drug errors was 1 in 1,000 orders, so I was hoping that if we had a robust intervention, we might see half of that or a quarter of that,” says Dr. Galanter.


As he and Dr. Lambert point out, their team examined only instances where alerts occurred, so they cannot say for certain what the overall error rate is. The alerts were set to go off only for the list of drugs for which indications has been identified. Theoretically, many more drug-name confusion errors may have gone undetected. Still, these latest results support implementing clinical decision support in CPOE to prevent wrong-drug errors, just as previous research showed alerts can also prevent wrong-patient errors and that they can help clinicians populate the problem list.


“What these results show is the potential power of trying to connect indications, diagnoses, and medications in the electronic medical record,” said Dr. Galanter. “Trying to look at those three pieces of information is probably a very fruitful area for future research.”


This research was published in the July 2014 issue of PLOS One. View the study paper online at

Does your organization use the electronic medical record to flag potential drug-name confusion errors? Comment on this post below.

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Patricia McTiernan is editor of the P.S. Blog. Contact her at

Tags:  CPOE  decision support  med errors  problem list 

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How Risk Management and Patient Safety Intersect: Strategies to Help Make It Happen

Posted By Administration, Tuesday, March 24, 2015
Updated: Tuesday, March 24, 2015

This article describes the journey of integrating patient safety and risk management and reports a 62% overall reduction in hospital professional liability premiums over 10 years that has occurred as a result of the integration and a dramatic increase in the reporting culture.

By Jamie Leviton, MHA, CPHQ, and Jackie Valentine, MHA, Rph

Engaging health care professionals and staff around reporting errors to reduce risk and improving the safety culture is a crucial but difficult task for many organizations. Unless staff members are engaged, feel safe to speak up, and are enabled to learn from the occurrence of preventable medical errors, poor patient outcomes will likely continue to occur. How organizational leaders respond to safety events and communicate to staff, patients, and family members following such events is key to building high reliability organizations and enhancing safety cultures.


A report published by the NPSF Lucian Leape Institute, Shining a Light: Safer Health Care Through Transparency, describes transparency as the most important element among the Institute’s recommendations necessary to transform the health care industry. In most organizations, the risk management and patient safety departments are separated in goals, scope, and leadership. In 2006 Virginia Mason chose to integrate the risk management function into the patient safety department and since then have utilized the Virginia Mason Production System (VMPS) management methods, to continuously improve the patient safety system by enhancing transparency in reporting, disclosing, mitigating risk, and improving patient safety.


This article shares the journey of integrating patient safety and risk management and reports a 62% overall reduction in hospital professional liability premiums over 10 years that has occurred as a result of the integration and a dramatic increase in the reporting culture.


The Patient Safety Alert System (PSA system) is the cornerstone of safety and quality for staff and patients at Virginia Mason. The PSA system began in 2002 and has been the focus of an on-going initiative to:

  • Encourage reporting and a culture of safety
  • Produce a rapid and standardized response to identified concerns
  • Empower managers to address issues close to the source
  • Promote greater transparency

The PSA system requires any employee who encounters a situation that has harmed or has the potential to cause harm to a patient to report a PSA and take actions to “stop the line.” Approximately 800-1000 PSAs are submitted per month via the online incident reporting system. Each PSA is reviewed by a patient safety specialist, who makes an assessment of the severity of the PSA based on whether there was harm or potential harm to a patient. The assessment by the patient safety specialist determines whether the PSA will be handled by the manager of the operational area or by a higher level administrator. For those PSAs that require a more intensive review, the patient safety specialist partners with the accountable executive and a multidisciplinary team to facilitate a root cause analysis and corrective action plan.


At Virginia Mason, risk management and patient safety are not separate, they are one in the same. We believe our patient safety program is our most effective risk management tool and have structured our department to focus on identifying safety risks and mitigating them quickly which allows for improvements to safety for patients while reducing risk to the organization at the same time.

There are 3 key strategies for how patient safety work is leveraged to reduce risk:

  • Culture of safety that encourages reporting of events
  • Leadership training and engagement
  • Early notification and collaboration with risk management (disclosure, support, etc)

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Culture of Safety

The first strategy is the culture of safety. While Virginia Mason has a relatively good degree of reporting, there are opportunities to improve communication around patient safety events and develop a culture where staff feel safe to speak up. The safety system should not be perceived as punitive, and staff members should be engaged in the solutions to identified safety issues. Armed with the VMPS management method and the support of dedicated team members, Virginia Mason has explored new and innovative ways to approach safety. The first step was to create a shared vision of patient safety at VM. A group of staff and leaders was brought together to come up with a vision statement: “To be inspired and prepared to take the right action, at the right time, with the right resources.” In addition to developing the vision statement, the team developed a future-state model and a three-year Kaizen plan, or work plan that has provided the roadmap for accomplishing the vision.


Critical concepts of the vision include:

  • Safety is deliberate.
  • Safety work utilizes VMPS and is aligned organizationally.
  • Safety starts and ends on the front line.
  • Engaging in safety is simple, fast and intuitive.


Five strategies are used to accomplish these goals: prevent, detect, respond, analyze, and learn/teach.

Communicating with staff about safety and celebrating success is critical to maintaining the culture, encouraging reporting, and normalizing the behaviors of speaking up and taking actions to improve safety.

All leaders at VM are expected to discuss safety issues with their staff regularly at huddles and staff meetings and ask for their ideas on how to improve systems and processes. Engaging the teams in discussing the problems and developing solutions gives them ownership and pride in improving safety every day. Safety is communicated at not only the local level, but also the organizational level, through a communication plan developed to raise awareness of patient safety and publicize some of the successes resulting from safety work.


The Good Catch Award is a celebration of a staff member who reported a PSA that had a compelling story which led to system improvements. The winner is presented with a certificate and a logo baseball signed by members of the quality oversight committee and is recognized on the website and at several leadership meetings. This award helps to stimulate conversation about safety and encourages staff to report safety issues. It is also used to publicize some of the great improvements that have been initiated as a result of those reports.

Reaching out to physicians and engaging them in safety and reporting is a critical element to building and maintaining a culture of safety. One strategy used at VM to engage physicians is PSA Pointers, a series of succinct educational presentations designed for the busy practitioner. Each PSA Pointer is created by the Continuing Medical Education office and is based on an actual Patient Safety Alert involving a gap in knowledge. The story of the PSA and the educational lesson is highlighted in fewer than 5 minutes through a video presentation. Each time a new PSA Pointer video is created, clinical staff receive an email notice with links to the video site.

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Leadership Training and Engagement

In order to ensure that the leadership across the organization shares the same mental model of patient safety, a patient safety orientation for all new leaders was developed. The training covers the history of patient safety at Virginia Mason, the expectations for leaders around communication with their staff related to safety, and the commitment to a non-punitive environment that provides tools and resources they can use to investigate and resolve safety concerns. Each leader is partnered with a patient safety specialist to mentor them through their safety journey and serve as a resource and team member.

Integration of Risk Management Function

At Virginia Mason, we do not have a risk management department. The function of managing claims is done within the patient safety department by claims specialists, but our philosophy is that the patient safety work is our strongest risk management tool.


All of the work related to improving culture and engaging leaders and staff in patient safety is key to the success of our risk management function. The patient safety department works closely with the claims team to ensure that they are notified early of any potential risk-related events. The claims team is able to evaluate potential risk events early, support providers and teams through disclosure, and work proactively to resolve patient complaints. Learning about potential risk events early allows the claims team to act sooner to mitigate that risk and not only protect future patients, but improve on the experience of the patient affected. In addition, the patient safety staff has worked closely with the patient relations team to develop a program for synchronized ongoing support (SOS) to respond to unexpected incidents such as reportable events and unanticipated deaths. We created a process available 24/7 that leverages our current resources including patient relations as well as spiritual care for staff and patients, patient safety, and leadership. This program serves to provide immediate and ongoing support for our patients, families, and team members and to initiate the investigation for process improvement.


To evaluate the impact of the safety initiatives, the number of PSAs reported per month was measured. At baseline, there were 430 PSAs reported each month; recently the numbers have increased to the goal of 1000 PSAs per month. More PSAs are not an indication that we are less safe, but that our teams feel safer to report—which is the ultimate goal. In addition to incident reports, culture metrics are measured. Each year staff at VM take a safety culture survey. The survey includes questions assessing the degree to which staff feel they are informed about errors on their unit, receive feedback about changes put into place based on incident reports, and participate in discussions to prevent errors from happening. Spot checks of the safety survey results have been favorable.


Finally, reported malpractice claims have fallen by approximately 50% at the same time PSA reporting significantly increased. There has been a 62% overall reduction in hospital professional liability premiums since 2006. The results show that the investment in a culture of safety and process improvement related to staff-identified safety concerns, coupled with robust communication and leadership training, can really impact the bottom line—which is good for patients and for the organization.

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Do risk managers and patient safety staff collaborate at your organization? Comment on this post below.


Jamie Leviton is manager, patient safety, at Virginia Mason Medical Center. Contact her at Jackie Valentine is director, patient safety, at Seattle Children’s Hospital. Contact her at

Tags:  risk management  transparency 

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