Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative
Abstract
Based on lessons learned through implementation of the Pittsburgh Regional Healthcare Initiative's region-wide shared learning model, we have identified the environmental, cultural, and infrastructure changes in health care that will be necessary to achieve significant, widespread patient safety improvement. However, the issues that arise are (1) approaching patient safety as a systems problem, and (2) overcoming challenges that arise when working across 40 hospitals to improve medication safety and infection control through regionwide reporting, information sharing, and problem-solving. Despite regionwide advances in awareness, knowledge, and action regarding patient safety, limitations of current reporting systems and realities constraining their use inhibit widespread error reporting, timely and effective information sharing, and adoption of real-time practice changes that lead to improved patient outcomes. Achievement of improved patient safety requires enhanced health care leadership commitment and learning systems that enable everyone in an organization to identify and solve safety problems to their root cause in real time and share what is learned.
Document Details
- Document Type
- Technical Report
- Publication Date
- Jan 01, 2005
- Accession Number
- ADA434296
Entities
People
- Carl A. Sirio
- Carlene A. Muto
- Donna J. Keyser
- Heidi Norman
- Robert J. Weber
Organizations
- United States Agency for Healthcare Research and Quality