patient safety assessment

"human-factors tool to educate staff about patient safety in the context of the system"

Challenge

Stop or reduce systemic patient safety errors.  Teach the hospital staff that patient errors are often a function of the design of the system versus individual practitioner errors.

Actions

Led the design and implementation of a system-wide education workshop on patient safety from a human factors perspective.  Then created a new risk assessment tool and investigation methodology to track and evaluate patient errors and mitigate patient safety errors.

Results

Staff acquired new skills that shifted the focus from "blaming" the clinician for the errors to recognizing the implication of the design of the system, which ultimately led to new procedures, fewer incidents, and more thorough investigations.