Past Projects

Implementing a Program of Patient Safety in Small Rural Hospitals - AHRQ Grant #: 1 U18 HS015822

Team Members: Katherine Jones, PhD, PT; Anne Skinner, RHIA; Gary Cochran, PharmD; Alana Knudson, PhD; Susan Beattie, RN, BSN; Keith Mueller, PhD

Final Report

In July of 2005, the Agency for Healthcare Research and Quality (AHRQ) awarded the University of Nebraska Medical Center a two-year Partnerships in Implementing Patient Safety (PIPS) grant.  The purpose of this project is to implement the patient safety practices of voluntary medication error reporting and organizational learning to improve the safety of medication use in small rural hospitals. This intervention took place in 35 Critical Access Hospitals (24 in Nebraska, 1 in Wyoming, and 10 in North Dakota) from July 2005 through June 2007. Through workshop activities and conference calls we provided project hospitals with the opportunity to: (1) conduct aggregate root cause analysis of non-harmful errors to determine system sources of error, (2) compare their current medication use processes to evidence-based best practices, (3) implement structured communication and teamwork training, and (4) assess the culture of safety within each organization using the AHRQ Hospital Survey on Patient Safety Culture (HSOPSC). 

We use two theoretical frameworks to organize the tools that we developed in this project. The first framework is that a safe, informed culture must be engineered by understanding its four components and then deliberately implementing the practices that support these components (Reason, 1997). The second framework is a change model that organizations can use to successfully implement the practices that support a safe, informed culture. This change model targets senior leaders, team leaders, and front-line staff to engage, educate, execute, and evaluate change (Pronovost, 2006). The combination of these two frameworks organizes our tools by the four components of a safe, informed culture: reporting, just, flexible, and learning cultures. Then, within each of the components, we provide tools to engage the audience about the importance of the change, to educate the audience about what they need to do, to ensure the audience can execute the change, and to evaluate whether the change made a difference. 

This research is supported by the Agency for Healthcare Research and Quality, Partnerships in Implementing Patient Safety, Grant #:  1 U18 HS015822.  The contents of this product are the sole responsibility of the University of Nebraska Medical Center and do not necessarily represent the official view of or imply endorsement by AHRQ or the U.S. Department of Health and Human Services.