PSO Toolbox Sample - DUHS Patient Safety Center
Transcript of PSO Toolbox Sample - DUHS Patient Safety Center
Chaos, Culture, and Predictability
Improve predictability = less chaos = better safety- Standardized interactions, checklists, familiarity
Reduce predictability = more chaos = worse safety- New Manager, New Location, New Technology
Data Driven Triage of Improvement Tools
staffing levels inadequate?/info lost at shift change?: consider
Morning/Shift Briefings
Interdisciplinary patient management issues?: consider Daily Goals
Trouble resolving conflicts/lack of role clarity?: consider Shadowing
Exercise
Difficulty speaking up?: consider standardizing through SBAR or
using Critical Language
If staff lack consensus about quality and safety issues? Share “Safety as a System” module with staff:
www.dukepatientsafetycenter.org
Feel unsafe or unengaged in safety and quality?
Learning from Defects
Executive Partnership 4
PSO Toolbox
Morning Briefing
Easy to use, little training, quick
• Charge nurse, attending/fellow at 7:30am
• What happened overnight? – Adverse events, near misses, admissions and discharges
• Where should I begin rounds?
– high-acuity patients, patient flow
• “What are your concerns regarding potential problems for
today?”
– patient scheduling, equipment availability, outside patient
testing, staffing, and provider skill mix.
Jt Comm J Qual Patient Saf. 2005 Aug;31(8):476-9.
Critical Language
• Key phrases understood by all to mean “stop and listen to me – we have a potential problem”
– When you hear this phrase, grab an elbow and join in the request for clarity
• Allina – “ I need some clarity”
• United Airlines CUS program –– I’m concerned
– I’m uncomfortable
– this is unsafe… I’m scared