Lessons learned: Root cause analyses aim to protect patient safety
Penn State Health’s Patient Safety team has conducted several root causes analyses of recent safety events. It is now sharing the lessons learned to help managers understand their role in helping to promote patient safety and the risks that present themselves in workflows.
There’s a one in a million chance of someone being harmed while traveling by plane but a one in 300 chance of a patient being harmed while receiving care in the hospital. And for every one serious patient safety event, there are 1,000 near-miss events — 1,000 opportunities to detect and correct that problem before a patient is harmed. Penn State Health has many programs that focus on safeguarding our patients, but when safety events do occur, the health system is committed to understanding why they happened to prevent them from recurring.
The safety events shared by Patient Safety span different disciplines and care areas. One in the medical/surgical care area relates to clarifying orders, while another captures a fall with an injury. In procedural areas, one event deals with a retained surgical item, while three others are wrong site procedures.
Safety events resulting in harm are preventable through the following actions:
- Utilizing safety behaviors and error prevention tools encompassed in the SAFE bundle (Support the team. Ask questions. Focus on task. Effective communications).
- Reporting safety events into Midas, especially near-miss events when a patient is almost harmed, so that issues can be identified and corrected.
- Engaging in behavior that supports a culture of psychological safety.
Questions? Reach out to Patient Safety by email or by phone at 717-531-4060.
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