Cross-education and Shared Social Events Rebuilt Trust Between Anesthesia and Care Teams
Lack of communication and sentiment of unity.
Culture of Safety Tactics
A library of clinician-tested tactics for building a culture of safety in healthcare. Created by the APSF Patient Safety Priority Advisory Group on Culture of Safety, Teamwork and Clinician Safety. Click here to submit a tactic >>
Removing Last Names From ID Badges Protected Staff Privacy After Stalking Incident
A patient began stalking-like behavior on social media of one of our PACU nurses. The patient tried to “friend” and “follow” and even sent direct messages to staff member.
Peer-to-peer ‘Cup of Coffee’ Chats Stopped Unprofessional Behavior Before It Reached Leadership
Standardize the way our department manages unprofessional events starting with using a peer-to-peer and stepwise approach rather than an administrative approach.
We welcome submissions from clinicians, safety leaders, and frontline teams with tactics that are strengthening the culture of safety at their institutions.
Have a tactic to share?
Download our Submission Form.
Department-wide Communication Compact Standardized How Apps Escalate Intraoperative Events
With APPs (CRNAs and AAs) of varying experience levels, some who worked elsewhere, some who were locums staff, there was confusion about what intraoperative events were to be communicated to the anesthesiologists. Further, there was dissatisfaction from the APPs regarding…
A Simple Help Guide Gave Offsite Anesthesia Teams a Lifeline When Crises Hit
When anesthetizing patients offsite, the anesthesia providers are cut off from others in their department. Should a team need additional help, the local staff may not know how to call the charge anesthesia providers or obtain additional personnel to help…
An Anesthesia Care Team Optimization Committee (ACTOC) Reached Over 200 Clinicians to Repair Trust
Our anesthesia care team experienced an acute trust fracture in 2019 that significantly impeded communication and collaboration. Relationships between anesthesiologists and nurse anesthetists were ice cold and patient safety became a genuine concern. An outside facilitator was brought in to…
Suicide Awareness Training Taught Anesthesia Teams to Recognize Colleagues at Risk
After a follow-up on a peer-to-peer encounter, it was surprisingly found out that a member of the team had transient suicidal thoughts that were not identified. Peer support training, which was conducted by an outside national organization did not address…
Interprofessional Crisis Simulation Prepared Radiology Teams for Anesthesia Emergencies
Several safety incidents affecting patients under anesthesia in radiology settings prompted review of root causes. Many contributors and vulnerabilities pertaining to effective crisis management in these remote non-operating room locations were found. Crisis simulation training with participation of the entire…
Adverse Event Safety Dashboard Closed the Feedback Loop for Frontline Clinicians
Most of the time, we talk about the importance of reporting adverse events so that quality and safety leaders can review the event, and decide follow-up actions and potential systems changes. Rarely, do we discuss ways to share the outcomes…
Resident Safety Badge Buddy Gave Trainees 24/7 Access to Safety and Well-being Resources
Organization (The University of Oklahoma Graduate Medical Education Office) wanted to improve resident access to safety/well-being resources and did so in the form of an easy-to-use and always available badge card.
Standardized CVOR-to-CVICU Handoff Protocol Reduced Communication Gaps by 20%
Failure of an earlier effort to improve fidelity to new CVOR-to-CVICU handoff process.
A Change-management Playbook Helped QI Projects Survive Their Most Fragile Phase: Adoption
Lack of adoption of Quality Improvement (QI) projects by direct patient care providers in the direct patient care setting.
Process And Value Stream Mapping Exposed Hidden Bottlenecks After COVID-era Disruption
After three major disruptors to our practice: COVID, electronic health record implementation, and staffing shortages, we noticed decreasing efficiency throughout the spectrum of patient care. Specifically, delays in starting on time were highlighted as a major opportunity for improvement. Understanding…
Filters
