Washington University’s Dr. Nussenbaum has some tips in improving safety programs based on changes his institution made in 2009, after a sentinel event case occurred, in which an individual was held personally accountable for events that were largely the result of systemic problems.
Explore this issue:April 2012
- Give event reporting the importance it warrants. Dr. Nussenbaum and his department chair moved the monthly morbidity and mortality conference from Wednesdays at 6 p.m. to the second Wednesday of every month at 7 a.m., in place of one grand rounds. “We wanted to send the message that this process is important enough to take out one grand rounds a month to make sure it’s at a time when everybody can attend,” he said.
- Assign patient safety a home and a champion. Washington University provided formal training for Dr. Nussenbaum in patient safety through the Institute of Healthcare Improvement. “It sends the message that this is important enough that someone is assigned the responsibility to make sure it happens,” he said.
- Analyze cases in a Just Culture manner. Learn more and find tools and resources at justculture.org.
- Engage top-down leadership support. Dr. Nussenbaum had the full support of his department chair in the development of a new approach to patient safety and adverse event reporting. “Without that support, you cannot have a robust patient safety system,” he said.