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Moving to high reliability
By Joan E. Shook, M.D.
One of my many responsibilities as chief safety
officer at Texas Children’s Hospital is to
oversee the continued implementation of the
patient safety program. One of my goals is to
move our organization to one of high-reliability.
In high-reliability organizations, the culture
supports individuals drawing attention to
potential hazards or actual failures in order to
accomplish effective risk/error reduction
strategies. “Lessons learned” from near misses or
actual failures are openly shared and
incorporated into training. Proactive risk
assessment is continuously occurring based on the
acknowledgment of the high-risk, error-prone
nature of the organization’s activities and the
determination to achieve consistently safe
operations.
Texas Children’s Hospital, along with 24 other
Child Health Corporation of America (CHCA)
hospitals, participated in an assessment of how
hospitals are progressing in the area of patient
safety. The survey was broken down into the
following several components and the
organization’s progress since the last survey in
2001 was measured. The results were stratified
across the patient safety continuum, which ranges
from awareness to high-reliability. The following
reflects our progress as well as the progress of
the other participating hospitals.
We have made great strides in the past years, as
demonstrated in the assessment results, but we
must continue to push forward. One tool that will
help in moving toward high reliability is the new
electronic event reporting system. After
extensive review, Risk Monitor Pro by rL
Solutions was selected. Finalization of the
purchase agreement is in process with
implementation expected to begin after the first
of the year. Once implemented, the new event
reporting system will allow our continued
development of a nonpunitive, system-based
approached to error reduction.
Your continued support in event reporting is
critical. As front-line clinicians, physicians
are often the first to realize an unexpected
outcome has occurred and recognize the specific
system conditions leading up to the event.
Effective analysis of system-based causes can
only occur when a clear understanding of the
event is provided. Without your support, it will
be very difficult to develop a robust system that
collects large amounts of measurable data and
that will allow us to become a learning
organization.
In the coming months, I look forward to working
with you as the new event reporting system is
implemented across the entire Integrated Delivery
System.
Joan E. Shook, M.D., is chief safety officer
and chief of Emergency Medicine at Texas
Children’s Hospital and professor of pediatrics
and head of Pediatric Emergency Medicine at
Baylor College of Medicine.
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