9A S H R M J O U R N A L 2 0 0 5 V V O L . 2 5 N O . 4

By Debra Scott, RN, and Wayne Marchant, FASHRM

Dealing with patient safety issues in today’s society is a formi-dable task at best, but before these issues can be tackled,organizations must know what the real issues are and develop

new strategies in order to survive.Risk identification was our first step in accomplishing this goal.

Memorial Health’s challenge, as with most organizations, was toincrease awareness of the importance of occurrence reporting andto help staff understand what to report. And, through re-education,we have tripled our rate of reported events in less than three years.

While attempting to meet the first goal – risk identification –was not an easy feat, it was (and still is) a worthy endeavor. TheRisk Management Department awarded certificates to departmentsthat significantly increased their event reporting, as well as todepartments that significantly improved the quality of their reporting.

Rewards encourage reportingReinforcing/rewarding this good reporting behavior has been paramount to our continued success.

With the deluge of incoming reports, the RM team took thesecond step – risk analysis – on all occurrences in order to validatethe facts reported on and verify whether there was a breach in thestandard of care and/or policy and procedure. And, if it is deter-mined that there was an adverse event as well as a breach in thestandard of care and/or policies, a Significant Risk Event status isassigned and an intense Clinical Risk Analysis is conducted in order to better position the organization’s response to a potentialdemand/claim.

Assessing reported events also provides opportunities toimprove processes that are inadequate and/or ineffective.

Memorial collaborated with industry professionals in order toformulate and solidify our safety plan. Establishing and monitoringbehavior expectations such as communicating clearly, being committedto safety and paying attention to detail, is part of that plan. Askingclarifying questions, following policy and procedure and stopping tothink before performing a function whether it is giving medications,or calling a timeout before an invasive procedure are also part ofour safety initiative.

The plan also has empowered everyoneto help ensure that the expectationsare followed.

Reducing situations and behaviors that cause errors requires theconstant and diligent effort of everyone in the organization.Memorial’s leadership was persuaded that the costs associated with a system-wide error prevention plan were a worthy endeavor,because even if it prevented just one potentially tragic event, itcould save the organization millions. This led to the commitment of educating the entire organization and all physicians (as a pre-condition for privileges to practice at Memorial Health) on the behavior expectations and associated error prevention techniques. The plan also has empowered everyone to help ensurethat the expectations are followed because it is a worthwhileendeavor.

SUCCESS STORY

Advancing ERM participation through staff patient safety initiatives

continued on next page

SHARE YOUR SUCCESSContribute your Patient Safety or Risk Financing Success Story to be considered for future issues. Article length should not exceed800 words. Contact Joe Pixler at jpixler@aha.org; (312) 422-3987.

10 A S H R M J O U R N A L 2 0 0 5 V V O L . 2 5 N O . 4

There are times when error prevention training and analysisare not enough, so accountability has been another key to oursuccess. In dealing with global issues, such as patient identification,our accountability model helps ensure that noncompliant personnelare dealt with in an equitable manner. This equitable methodologyis being accomplished through an Accountability Panel. The managerinvestigates who, what, where, when, why and how the seriousadverse event occurred. The information is then presented to thepanel and collectively, the panel determines what action if anyneeds to be taken.

Collaboration helpsWhat has been described above is only a glimpse into what it hastaken for Memorial’s ERM program to be successful. Collaborativeefforts of Administration, Quality, Risk Management and Physiciansalong with a well defined ERM plan have helped facilitate thenecessary changes in order to provide a safer environment for ourpatients and staff. By designing and deploying these principlesMemorial Health has effectively decreased the number of significantadverse events and has literally saved the organization millions inrisk financing and claims costs.

Debra Scott, RN, is loss prevention analyst, scottde1@memo-rialhealth.com, and Wayne Marchant, FASHRM, is vice president,Corporate Risk Management and Insurance, at MemorialHealth, Savannah, GA. marchwa1@memorialhealth.com

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