Creating an integrated patient safety team.

Unlabelled: CREATING A PATIENT SAFETY TEAM: In May 2001 Brigham and Women's Hospital (Boston) created the Patient Safety Team, which was incorporated into the pre-existing safety and quality infrastructure. ESTABLISHING THE PATIENT SAFETY TEAM'S GOALS AND INITIATIVES: The goal was to create the safest possible environment for patients and staff by creating a culture of safety, increasing the capacity to measure and evaluate processes, committing to change unsafe processes, and adopting new technologies. To achieve this mission, the following initiatives were established: create a culture of safety, increase event identification, improve event analysis, close the feedback loop, assess risk proactively, improve medication safety, and involve the patient.

Patient Safety Leadership WalkRounds.

Background: In the WalkRounds concept, a core group, which includes the senior executives and/or vice presidents, conducts weekly visits to different areas of the hospital. The group, joined by one or two nurses in the area and other available staff, asks specific questions about adverse events or near misses and about the factors or systems issues that led to these events. ANALYSIS OF EVENTS: Events in the Walkrounds are entered into a database and classified according to the contributing factors.