“Patient Safety Walk Rounds” program was established in January 2003. Walk Rounds are specifically designed to overcome the deficiencies of an incident, report-based detection system and also allows administrators to speak directly with staff members who deliver direct care to the patient. This process promotes a free exchange of thoughts and ideas while enhancing a blame-free environment within the organization. Such interaction is fundamental to changing the culture of hospitals so that all employees truly believe that safety is a priority and a core institutional value.

 

In each hospital, a designated Safety Team makes “Walk Rounds” on a monthly basis. The Team is comprised of a Safety Officer/Risk Manager, a pharmacist, Quality/Education personnel, a recorder and the President or Vice-President of the hospital. Members of the Safety Team interview hospital staff and answers are tabulated using a 12-item questionnaire. Comments and observations by hospital personnel are recorded and categorized, scored according to risk, probability, and severity. Unit managers are encouraged but not required to participate in these rounds, as a result managers frequently accompany the Safety Team; however, the primary motive of the Safety Team is to speak with and involve caregivers in order to truly understand and assess safety issues from the perspective of employees who do the work in member hospitals.

 

Data is gathered it will be categorized and rated by severity and probability. Severity denotes the potential for harm and the probability implies the likelihood of occurrence within the system. Once the data is reconciled on the Healthcare Failure Mode and Effect Analysis (HFEMA) tool, it can then be entered into the DICON Safety Program database. This is an access database that will allow for entry of each issue by: A) Number; B) Date; C) Unit/Dept; D) Description; E) Potential cause; F) Category; G) Adverse drug event; H) Severity score; I) Probability; J) Action Taken; K) Outcome measures; L) Person Responsible; and M) Completion date.

 

The program will automatically compute the hazard score for each issue identified and entered into the database. The score becomes an indicator of the level of hazardous potential associated with the selected process. This should assist the Safety Team in triage the highest to lowest risk on the decision tree for implementing process and system changes to improve patient safety.

 

Reports that can be utilized from the database will assist the hospital with internal safety data and benchmarking data with other hospitals related to categories, issues, hazardous scoring rates and outcome measures.

 

Resources Example of Safety Program letter to CEO Example of Summary Report Graphs with Safety Data: Hazard Scores Overall Hazard Scores by Category Communication Incidents Hazard Scores Equipment Incidents Hazard Scores Human Error Incidents Hazard Scores Medicine Incidents Hazard Scores Staffing Incidents Hazard Scores Other Category Incidents Hazard Scores Current Incident Status Awareness of Blame Free Culture Successful Solutions from Patient Safety Walk Rounds

Member Institutions Alamance Regional Medical Center Cape Fear Valley Medical Center Person Memorial Hospital