The Richard and Hinda Rosenthal Lectures 2003 Keeping Patients Safe -- Transforming the Work Environment of Nurses (2004) / Chapter Skim
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Evidenced-Based Management and a Culture of Safety--William C. Rupp, M.D.
Evidenced-Based Management and a Culture of Safety--William C. Rupp, M.D.
Pages 14-18
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From page 14... ...
I won't give the whole outline but just some examples of the kinds of things that can be done in health-care organizations. This comes directly off of recommendation 5.2 that we employ nurse staffing practices that identify needed staffing for each patient care unit per unit, empowering nursing unit staff -- and I emphasize nursing unit staff -- to regulate work flow and set criteria for unit closure to new admissions and transfers as nursing workload and staffing necessitate.
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From page 15... ...
As a leader, it means that I admit I don't have the faintest idea in most cases what happens at the sharp end of health care, at that individual point of care delivery, and going to those people and asking them the best way to do things and then finally establishing a learning organization. Now, let me show you a specific example that comes out of my previous site.
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From page 16... ...
" These are the reported medical errors on one unit back in about 1998 when we started collecting some of these data by month, and then we began a process of going out. The head nurse and I actually went around to every single unit on every single shift and said, "Do you know how important it is that we start finding out about these errors?
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From page 17... ...
We found 5 per 100 admissions. We were flabbergasted; 23 potential adverse events per 100 admissions, 14 pharmacy interventions, and in those 6 weeks there were seven major adverse drug events.
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From page 18... ...
There are a number of different ways it requires us as health-care leaders to think differently about our organizations and working with the multiple professional organizations, but those 10 recommendations are doable and there is data and management data to show that we can dramatically increase the safety of our organizations.
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