Toward a Higher Standard of Safety

Building the Department-Level Safety Strategy

Topics: Quality and Service, Operations Skills, Skill Development, Workforce, Safety, Quality, Performance Improvement

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  • Toward a Higher Standard of SafetyToward a Higher Standard of Safety


    Pamela Porter and JoNeil Smith discuss the workshop Toward a Higher Standard of Safety, which prepares leaders to proactively and effectively advance patient safety in their sphere of influence.

Workshop Overview

Despite years of concentrated effort, a large body of evidence suggests that patients are no safer today than in 1999 when the Institute of Medicine released its ground-breaking study To Err Is Human. Efforts since have typically taken an organizational approach: Strategy is largely dictated by Joint Commission goals, overseen by an office of patient safety, and monitored by an organization-wide steering committee.

Research demonstrates that while this institutional approach is necessary, a departmentlevel safety strategy is best to achieve patient safety reform. This course will enable leaders to diagnose latent failures, assess the readiness of the culture to surface these failures, and properly dispose of processes that may mask or even exacerbate current safety problems. Overall, participants will learn a framework for structuring proactive plans to improve the safety of patients.

Learning objectives for participants

  • Leverage their roles to improve patient safety
  • Distinguish among harm, errors, and latent failures and understand where to focus their safety agenda
  • Foster a culture that encourages team learning in the service of patient safety
  • Recognize, qualify, and dispose of process workarounds that compromise safety efforts

Course content and teaching methodology

This course incorporates classroom presentation, case studies, and individual and group exercises. The following topics are among those included in this course:

Recognizing the safety imperative

  • Understanding how we become numb to risk
  • Learning how to overcome limitations of organizational approaches to safety

Redefining the safety problem

  • Distinguishing among harm, error, and latent failures
  • Focusing the safety agenda on the potential for harm
  • Using a customized search tool to guide the identification of safety threats

Shifting the culture

  • Understanding how interpersonal fears and team dysfunctions endanger patient safety
  • Encouraging a team setting that surfaces and resolves potential sources of harm

Analyzing Workarounds

  • Understanding the potential safety threats posed by process workarounds
  • Analyzing workarounds to determine how they can be eliminated