Our goal is to decrease preventable harm by providing a safe and healthy environment that encourages the reporting of errors, unsafe practices and near misses that may result in harm. The primary focus of the plan is to improve system factors that affect patient safety. Our efforts depend on the involvement of all staff and providers within all levels and areas of the organization. We will promote the active participation in the patient safety experience by all, which is done in collaboration with the environment of care and employee safety programs.
- All leaders model appropriate patient safety actions and advocate for the elimination of intimidating behaviors supporting an effective patient safety system.
- A transparent, just and non-punitive approach will build a safer reporting culture and allow for sharing of lessons learned of system vulnerabilities.
- All staff and providers are responsible for promoting and supporting a safety culture by reporting adverse events, close calls and unsafe conditions.
- A culture of safety across the organization will identify strengths and opportunities for system enhancements and improvements.
- All staff and providers are responsible for partnering with patients and families by listening with compassion, communicating effectively and being respectful.
Create a Patient Safety Culture by ascribing to the following:
- Just Culture in which people are encouraged and in some cases rewarded for providing essential safety-related information, while drawing a clear line between acceptable and unacceptable behavior;
- Learning Culture which requires both willingness and the ability to draw the right conclusions from its safety information system and to have the will to implement major reforms;
- Informed Culture where those who manage and operate the system have current knowledge about the human, technical, organizational and environmental factors that determine the safety of the system as a whole.
- Trust - Report - Improve Leaders foster trust which enable staff to report which enables the organization to improve. Staff sees that their reporting contributes to actual improvement which bolsters trust.
- Encourage reporting of events, near misses and risks to patient safety without judgment (non-punitive), noting human errors and system errors from unsafe, blameworthy actions.
- Provide systematic/standardized responses to identified concerns.
- Improve safety by collecting and analyzing data to identify and evaluate care processes for opportunities to reduce risk and initiate process improvement.
- Promote and support transparency by reporting on what has been found, actions taken (with a focus on processes and systems), and share knowledge through lessons learned in order to affect change.
AHRQ PSN Net
Clinical In Brief
Patient Safety and Quality Health Care
PSN (Patient Safety Net)
PSN (Patient Safety Net) Downtime Form (UW Health)
Josie King Story
The Joint Commission on Patient Safety