by Ellen Flynn, RN, MBA, JD
Associate Vice President, Safety Programs

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, to resolve a longstanding issue in which imaging tests get ordered without the clinical indication, Vizient PSO recommended that organizations develop an electronic process with a forcing function that requires the ordering provider to enter the reason for the study, the associated ICD-9 code, any pertinent medical history and the patient’s clinical signs and symptoms into the computerized order to improve the accuracy of the radiologist’s interpretation. The recommendations in the Vizient PSO safety alert on closing the loop on actionable radiology findings were compiled in collaboration with a multidisciplinary team from Vizient organizations.

Within the Vizient Performance Improvement Collaboratives, there are two projects being offered in 2021 that directly focus on patient safety, and allow members to work collectively with other members: Sepsis Early Recognition Collaborative (enroll by April 9) and a High Reliability to Reduce Variation Collaborative (enroll by April 23).

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.

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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.

Published: March 15, 2021