Identifying Patient Safety Issues at the Unit Level Can Lead to Systemwide Change

September 4, 2013 | Strategic Insights for Health System


Using Patient Safety Leadership Walkrounds™ at the unit level (instead of using it to increase senior leadership’s involvement in patient safety), one organization identified various safety concerns that affected the entire facility, states an article published in the September 2013 issue of The Joint Commission Journal on Quality and Patient Safety. Six medical/surgical units were used as the pilot for this project. Each unit has a nurse manager and medical director as the champions of the initiative, which had four phases: (1) the nurse and physician leaders assembled a group of frontline staff to complete a unit safety assessment; (2) patient safety concerns were discussed among the group of frontline staff; (3) the findings from the group were discussed with the local unit quality and safety committee; and (4) the findings were then discussed with unit leaders to identify facility-wide safety issues. Almost 150 people participated in the initiative, ranging from nurses and physicians to child life specialists and parents. A few issues identified by frontline staff were prevalent throughout the entire facility.

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