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Welcome to the Indiana Patient Safety CenterThe Indiana Patient Safety Center was formed in July 2006. The main function of the center is to provide education, training, and other tools to foster cultures of safety in the complex work environments of Indiana’s hospitals. The center’s plan is to encourage and facilitate evidence-based practices to reduce delivery system failures that could cause harm to patients. Patient Safety Update Nurses on the Front Lines for Patient Safety: On Sept. 29, Besty Lee, director, Indiana Patient Safety Center, spoke to nearly 200 nursing students during Indiana University School of Nursing's Professional Development Day. Indiana Pressure Ulcer Quality Improvement Initiative: Hospitals interested in participating in the Pressure Ulcer Quality Improvement Initiative should submit a letter of intent to the University of Indianapolis by Oct. 1. The initiative, originally targeted to long term care facilities has recently been expanded to include hospitals and home health agencies. Up to 50 hospitals will be included in the initial collaborative. For more information, contact Betsy Lee, director, Indiana Patient Safety Center, at blee@ihaconnect.org. Just Culture Stakeholder Meeting: On Sept. 30, the Indiana Patient Safety Center brought together key stakeholders from across the state to discuss moving forward with a statewide just culture initiative. The meeting was a follow up to the presentation by David Marx at the IHA Annual Meeting regarding just culture and patient safety. Hospitals to Consider Standardized Colors for Alert Wristbands: The AHA is asking all hospitals to consider using three standardized colors for alert wristbands to improve patient safety. All hospitals are invited to attend one of two AHA informational calls on the topic scheduled for Sept. 19 and 23. The colors, which have been adopted as a consensus in numerous states, are: red for patient allergies; yellow for a fall risk; and purple for do-not-resuscitate patient preferences. Visit http://www.ahaqualitycenter.org/ahaqualitycenter/jsp/home.jsp for more information. The Council on Quality and Patient Safety will discuss strategies for statewide implementation at its September meeting. Recognition: Joshua B. Fleming , manager of clinical operations Newborn ICU, Clarian Health, Indianapolis, and Rebecca L. Royer, director of hospital review services, Health Care Excel, Terre Haute, were named 2008-2009 Patient Safety Leadership Fellows by the Health Research and Educational Trust. AHRQ Creates Guide to Prevent Blood Clots Pennsylvania Patient Safety Authority Releases Advisory: Analysis shows more than 3,800 medication errors may have been prevented if documented information about the patient was adequately communicated before the medication was prescribed and given to the patient. 2007 Indiana Medical Error Reporting System Statewide Culture Survey--Over 19,00 Surveyed
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What is Just Culture? The just culture paradigm addresses the weakness of a blame-free approach to errors and near-misses but also runs counter to an overly-punitive culture. One of the leading authorities on the topic, David Marx, describes it this way: "On one side of the coin, it is about creating a reporting environment where staff can raise their hand when they have seen a risk or made a mistake. It is a culture that rewards reporting and puts a high value on open communication—where risks are openly discussed between managers and staff. It is a culture hungry for knowledge. On the other side of the coin, it is about having a well-established system of accountability. A Just Culture must recognize that while we as humans are fallible, we do generally have control of our behavioral choices, whether we are an executive, a manager, or a staff member. Just Culture flourishes in an organization that understands the concept of shared accountability—that good system design and good behavioral choices of staff together produce good results. It has to be both."
To learn more, visit http://www.justculture.org/
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