Staff at a Maryland hospital discovered a patient safety issue with insulin pens that was traced to the electronic medical record’s (EMR) inability to generate patient-specific labels efficiently. A root cause analysis revealed the process gaps, and staff developed a solution that ensures patients receive insulin doses only from their own pens.
The patient safety movement emphasizes the need to focus on detecting harm — ideally, preventable harm — rather than just errors. Instead of remaining hidden, adverse events should be identified and shared.
When Doylestown Hospital in Pennsylvania received a C on the Spring 2016 Leapfrog Hospital Safety Grade, leaders launched a campaign to improve patient safety. A central tactic was adapting its staffing model to meet Leapfrog’s ICU Physician Staffing criteria.
The plan is built on four foundational areas developers contend all must be addressed to advance safety: leadership and culture, patient and family engagement, workforce safety, and the learning system.