The goal of this project is to develop and implement close-call reporting systems in clinical units of three hospitals, analyze the frequencies of close calls and identify underlying causes, and develop a series of quality improvement (QI) projects to reduce close calls and system failures in those units. Drawing on the strengths of this center for patient safety, we will also integrate lessons learned from other center projects. These include understanding the cognitive science of error (project 1, Zhang); and surveys used to assess organizational culture (project 4, Helmreich). This project will also rely upon Dr. Helmreich?s experience in designing a near-miss reporting system for aviation (Aviation Safety Action Partnership, ASAP) and the extensive experience of the Performance Improvement Department of MD Anderson Cancer Center, which will lead the project. This project?s specific aims are to: 1) Design and implement a close-call reporting system at each study site, using clinical (""""""""front-line"""""""") staff (physicians, nurses, pharmacists) to inform the process; and 2) Design and implement quality improvement projects to reduce error based on analysis of reported close calls, and assess the results of the QI projects in addressing the close calls.
| Profit, Jochen; Etchegaray, Jason; Petersen, Laura A et al. (2012) Neonatal intensive care unit safety culture varies widely. Arch Dis Child Fetal Neonatal Ed 97:F120-6 |
| Profit, Jochen; Etchegaray, Jason; Petersen, Laura A et al. (2012) The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU. Arch Dis Child Fetal Neonatal Ed 97:F127-32 |
| Tamuz, Michal; Giardina, Traber Davis; Thomas, Eric J et al. (2011) Rethinking resident supervision to improve safety: from hierarchical to interprofessional models. J Hosp Med 6:445-52 |
| Simmons, Debora; Sherwood, Gwen (2010) Neonatal intensive care unit and emergency department nurses' descriptions of working together: building team relationships to improve safety. Crit Care Nurs Clin North Am 22:253-60 |
| Etchegaray, Jason M; Throckmorton, Terry (2010) Barriers to reporting medication errors: a measurement equivalence perspective. Qual Saf Health Care 19:e14 |
| Williams, A L; Lasky, R E; Dannemiller, J L et al. (2010) Teamwork behaviours and errors during neonatal resuscitation. Qual Saf Health Care 19:60-4 |
| Etchegaray, Jason M; Sexton, J Bryan; Helmreich, Robert L et al. (2010) Job satisfaction ratings: measurement equivalence across nurses and physicians. West J Nurs Res 32:530-9 |
| Frankel, Allan; Grillo, Sarah Pratt; Pittman, Mary et al. (2008) Revealing and resolving patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient safety. Health Serv Res 43:2050-66 |
| Singh, Hardeep; Thomas, Eric J; Petersen, Laura A et al. (2007) Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med 167:2030-6 |
| Singh, Hardeep; Thomas, Eric J; Khan, Myrna M et al. (2007) Identifying diagnostic errors in primary care using an electronic screening algorithm. Arch Intern Med 167:302-8 |
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