Develop evidence-based solutions to patient safety problems
Your health care organization is unique and has distinct needs. Use the best available evidence to develop interventions, and test them before scaling organization-wide.
Making changes across your whole organization may be challenging in terms of finding time and resources or getting buy-in from staff.
Start with a small test. Pick an area to try a new intervention, look for the area with greatest need or an area with supportive staff.
Collect information about what is going wrong and why the problem is happening. See Objectives for tools such as flow charts to help guide this process.
Not sure where to start? This "change package" offers concrete examples of changes to test, developed specifically for use by small medical offices in Massachusetts as part of the PROMISES project.
Monitor and discuss the importance of best practices published in the literature and professional guidelines.
Monitor patient safety alerts to be sure you’re aware of device failures, or common mix-ups with similarly-named medications.
Learn from other organizations’ successes and failures. Share your findings and stories freely with peers.
Adapt interventions based on testing results
When you identify a problem, select and test an intervention to determine if it is successful. If the intervention is not working, stop here. If it works well, expand it to other areas of the organization.
Observe how the intervention performs.
Ask patients and family members for feedback on the intervention. Consider approaching people at a time when they are already onsite; for example, while they sit in the waiting room.
Alter the intervention as necessary to improve it.
If the intervention is not working, stop here. If it works well, expand it to other areas of the organization.
Staff members who participated in the test can facilitate this process. They can serve as a resource for other staff and provide motivation by corroborating the effectiveness of the intervention.
Technology can be a powerful patient safety tool, but it can be a mistake to rely on technology alone. It is important for staff to think critically about each case. For example, a staff member may notice that a patient is not clinically able to take a medication that is listed in an electronic system.
Resources that may help patient safety when used effectively include prescription/electronic medical record safety checks, decision-making support, and bar codes to confirm medication or patient identity.
