This page will contain important information on patient safety from WVUH VP Armistead. These topics are important to patient care, and are great examples of Systems Based Practice and Problem Based Learning and Improvement competencies.  More of these bulletins will be posted as they become available.

 

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WVUH, as the primary teaching hospital for the GME programs sponsored by the West Virginia University School of Medicine, has launched a patient safety education campaign. This continued collaboration will optimize quality and patient safety at WVU. One area to  improve  is communication about adverse events and near-misses.  It is well known that the best way of dealing with adverse events is to move away from a "culture of blame" to a "culture of safety".  This involves identifying the root cause(s) of an incident and then using the findings to drive system change, a process known as "root-cause analysis" or RCA.  During this past year (2007), a number of such RCAs were conducted and led to significant system improvements.  However, if the only folks who learn about these causes and fixes are those involved in the event and/or the investigation, then our patients are still vulnerable to a repetition of the error, perhaps on a different unit or with a different provider(s).  It makes much sense to share such "lessons learned" with as wide an audience group as possible, in an open, actionable way.  We plan to post here a series of such documents that provides critical facts on a specific patient safety issue.      

Lessons Learned #1: Falls Prevention