Introduction of enterprise risk management in neonatal intensive care unit to reduce breast milk errors.

Preterm infants born before 34 weeks gestation are unable to feed by mouth. Mothers of these preterm infants are thus asked to pump breast milk to be fed to infants through a nasogastric tube. Each mother's pumped breast milk must be carefully labelled and stored so that it is not fed to the wrong baby during the infants stay in the neonatal intensive care unit, which can range from days to months. All hospitals have strict policies and procedures in place to ensure infants are fed their mother's milk but still occasional errors are reported. We looked at the effect of introducing the enterprise risk management method in preventing breast milk errors in our neonatal intensive care unit.

2010 Annual National Patient Safety Foundation Congress: conference proceedings.

On May 17Y19, 2010, the National Patient Safety Foundation(NPSF) held its Annual Patient Safety Congress in Orlando, Florida. Entitled 'Getting Results: Solutions That Work', the meeting reinforced the need to focus on critical work in patient safety as health care reform begins to unfold. Without this focus, the industry will not be able to realize the Institute of Medicine's aims for safer, more efficient, equitable, timely, and truly patient-centered health care. The NPSF Congress provided meaningful content through plenary and breakout sessions that discussed a variety of real-world tools, resources, and evidence-based solutions to safety issues. The Congress was co-chaired by 2 distinguished leaders in patient safety: Doug Bonacum, MBA, BS, vice president for Safety Management at Kaiser Permanente and a member of the board of directors of NPSF; and Barbara J. Youngberg, JD, MSW, BSN, visiting professor in the School of Law at Loyola University Chicago and a member of the board of directors of NPSF. The main conference was preceded by 2 concurrent day-long workshops and 2 half-day workshops: Leadership Day: Creating An Accountable Culture to Drive Needed Change; Community Engagement from the Patient and Family Perspective; Simulation Fundamentals to Advance Your Patient Safety Agenda; and Measurement Boot Camp: Strategies and Tactics for the Real World. The Congress featured 4 plenary sessions, 35 breakout sessions, and the debut of the Learning and Simulation Center, which created an environment for attendees to engage in hands-on, interactive settings and provided real-world solutions to improve patient safety and quality of care. This article provides summaries of the plenary sessions.

Event reporting: the value of a nonpunitive approach.

This article will discuss why patient safety has been so hard to achieve due to long standing beliefs that when errors occur individuals must be blamed or punished. It will offer suggestions as to how a culture of learning can be advanced by fostering a different approach to medical errors and how reporting systems and an analytic process that always identifies root causes of problems can help physicians reduce harm to patients and ultimately malpractice risk.

Organizational factors associated with high performance in quality and safety in academic medical centers.

PURPOSE: Leaders of academic medical centers (AMCs) are challenged to ensure consistent high performance in quality and safety across all clinical services. The authors sought to identify organizational factors associated with AMCs that stood out from their peers in a composite scoring system for quality and safety derived from patient-level data. METHOD: A scoring method using measures of safety, mortality, clinical effectiveness, and equity of care was applied to discharge abstract data from 79 AMCs for 2003-2004. Six institutions (three top and three average performers) were selected for site visits; the performance status of the six institutions was withheld from the site visit team. Through interviews and document review, the team sought to identify factors that were associated with the performance status of the institution. RESULTS: The scoring system discriminated performance among the 79 AMCs in a clinically meaningful way. For example, the transition of a typical 500-bed hospital from average to top levels of performance could result in 150 fewer deaths per year. Abstraction of key findings from the interview notes revealed distinctive themes in the top versus average performers. Common qualities shared by top performers included a shared sense of purpose, a hands-on leadership style, accountability systems for quality and safety, a focus on results, and a culture of collaboration. CONCLUSIONS: Distinctive leadership behaviors and organizational practices are associated with measurable differences in patient-level measures of quality and safety.