Patient Safety-It's Not Rocket Science

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Dr. James P. Bagian has extensive experience in the fields of human factors, aviation, and patient safety. Dr. Bagian is the Director of the Center for Healthcare Engineering and Patient Safety and is a Professor in the Department of Anesthesiology and the College of Engineering at the University of Michigan. Previously he served as the first and founding director of the VA National Center for Patient Safety and as the VA’s first Chief Patient Safety Officer where he developed numerous patient safety related tools and programs that have been adopted nationally and internationally. A NASA astronaut for over 15 years, he is a veteran of two Space Shuttle missions including as the lead mission specialist for the first dedicated Life Sciences Spacelab mission. Dr. Bagian graduated from Jefferson Medical College. He is a Fellow of the Aerospace Medical Association, a member of the National Academy of Engineering, the Institute of Medicine, and has received numerous awards for his work in the field of patient safety and aerospace medicine.


This session will allow participants to:

1) Understand national and Jefferson specific safety data and the implications concerning patient safety. - The attendee will be able to identify vulnerabilities and formulate approaches to mitigate them.

2) Describe the goal of patient safety. – The attendee will be able to describe the rationale for selecting the goal of patient safety being the prevention of harm rather than simply identifying the elimination of errors.

3) Describe the importance of close calls/near misses in identifying patient safety vulnerabilities. – The attendee will be able to describe the superior utility to identifying and mitigating vulnerabilities identified through close call reporting rather than just responding to adverse events when they occur.

4) Identify the value of a non-punitive approach to problem identification and resolution. – The attendee will be able to describe how the removal of barriers to reporting will enhance the effectiveness of a patient safety program. In particular, the attendee will be able to describe impediments to reporting such as fear, shame, and administrative punishment as well as measures to ameliorate the impact of these impediments.

5) Describe the value of clearly defining what activities are blameworthy. - The attendee will be able to describe the essential elements of defining what constitutes a blameworthy action. Specific criteria include criminal acts, purposely unsafe acts, or acts committed under the influence of alcohol or illicit substances.

6) Describe the role that leadership at all levels plays in the institution of an effective patient safety program. - Specific examples of how leadership can demonstrate support to the organization will be covered. Examples include the requirement that top leadership must personally review and approve all root cause analyses and their corresponding corrective actions.

7) Identify strategies for prioritizing and ameliorating patient safety vulnerabilities. – The attendee will be able to describe the advantage of a risk based approach to prioritization rather than a more traditional one that only considers the severity of an event rather than also considering the probability of occurrence.

8) Understand the role of culture in providing safe and high quality patient care. - The attendee will be able to describe techniques and tools to enhance teamwork and improve safety culture in their immediate work environment.

Presentation: 52 minutes

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