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Patient Safety News: A Success Story of Culture Change
PA PSRS Patient Saf Advis 2004 Sep;1(4):19. 
 

Authors from the Missouri Baptist Medical Center (MBMC) recently published the results of a more than three-year effort to change their hospital’s punitive culture to a “just and fair” culture by implementing a number of patient safety-related practices. A series of focus groups found that staff members were reluctant to report safety problems because the reporting systems were time-consuming and intimidating, they did not believe it was appropriate to report “near misses,” and because they feared negative consequences from reporting.

MBMC embarked on a multifaceted patient safety program that included executive leadership commitment, structural changes in the organization, redesign of the reporting system, adoption of tools to aid event investigation and prevention, and a feed-back/communication component. Elements of the program cited as critical success factors were “highly visible behavior” by senior management to demonstrate their commitment to safety and the recruitment of “safety champions” among the medical staff and other front-line employees to lead specific initiatives. Other program elements included the creation of a new Patient Safety Specialist position to coordinate all related initiatives and the inclusion of patients as partners in helping to ensure safe care.

The authors measured the success of the program using outcomes derived from monthly employee surveys as well as through measures of the volume of events reported. For example, the number of events reported per 1,000 patient days more than tripled between the pre- and post-intervention periods. Use of a safety “hotline” increased even more dramatically over the study period, and the proportion of callers who felt comfortable enough to identify themselves doubled.

(Cohen MM, Kimmel NL, Benage MK, et al. Implementing a hospitalwide patient safety program for cultural change. Jt Comm J Qual Saf 2004 Aug;30[8]:424-31.)
 
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Patient Safety News: A Success Story of Culture Change



THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS  
PSA LOGO The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .      
ECRI LOGO ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.      

ISMP Logo The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.      
 
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