by Ellen Flynn, RN, MBA, JD
Associate Vice President, Safety Programs
03/12/20

The Institute of Medicine defines patient safety as “the prevention of harm to patients.” While great strides have been made in the name of patient safety in the last 20 years, efforts to improve safe care will continue to be a priority for the unforeseeable future.

To help ensure patient safety, health care leaders are dedicated to designing systems and processes that deliver highly reliable care and creating environments that facilitate open and honest dialogue that surfaces issues when they occur; where staff feel comfortable speaking up in the best interest of patients and their families. Hospitals are also taking steps like joining a Patient Safety Organization (PSO) to provide a secure, protected space for staff to learn from near-miss and adverse events in efforts to improve safety. All of these actions come together to create shared ownership for reporting among all caregivers without fear of blame for mistakes.  

Patient Safety Awareness week is dedicated to sharing the success stories of the ongoing, collective work of health care organizations to protect the patients who depend on them to follow the six aims of health care quality: delivering safe, effective, patient-centered, timely, efficient and equitable care. It is also a time to reflect on where gaps remain and the need to focus our efforts on the development of risk-reduction strategies to prevent failures leading to harm.

One very important way my organization contributes to this work is through our PSO, which supports efforts to create a safe learning space for staff to share patient safety learnings and opportunities within their organization, across their system and across the PSO membership. Each week, the Vizient PSO brings together members in safety huddles to share lessons learned about safety issues to prevent further patient harm at another organization.

For example, during the member huddle process, Vizient staff learned of the potential for newborn falls from incubators. This discovery triggered further investigation of this under-researched topic. The Vizient PSO team conducted an analysis of safety events on infant drops and falls across health care settings to identify the factors contributing to these incidents and met with member experts to develop leading practices for prevention. In addition, member concerns and recommendations for improving the safety of equipment were shared with manufacturers. The findings were compiled and presented in this Vizient PSO safety alert.

In addition to the PSO, Vizient members participating in our CMS Hospital Improvement Innovation Network project last year avoided more than 28,000 harm events. Within the Vizient Performance Improvement Collaboratives, there are two projects being offered in 2020 that directly focus on patient safety, and allow members to work collectively with other members: Antimicrobial Stewardship in Ambulatory Healthcare Collaborative and Components of High Reliability Benchmarking Study.

The work that Vizient is doing to help promote a culture of safety is very exciting. I believe that our offerings will have a positive impact on the lives of our members’ patients and their families. By helping our members design better health systems to prioritize the delivery of care in a highly reliable manner, we can improve outcomes. And in doing so, we can create an environment where it’s hard to make a mistake.

To better understand the work being done by the Vizient PSO to improve patient safety, read more.

About the author. Ellen Flynn is an associate vice president of safety programs on the Vizient performance management team and leads the Vizient PSO, helping members improve patient safety, health care quality and outcomes. She uses her extensive experience with both academic medical centers and large health systems to works with members on topics such as, “Just Culture,” “High Reliability,” “Human Factors” and “Culture of Safety.” Prior to her role at Vizient, Flynn held leadership roles in quality improvement, regulatory compliance and accreditation. She developed one of the first PSOs in the country and possesses a keen understanding of how to help members operationalize their patient safety activities when working with a PSO.