title: Organizational and cultural changes for providing safe patient care.
abstract: OBJECTIVE
  To describe an approach and experience with fostering a culture of patient safety.
  
  
  METHODS
  (1) Organizational Change-The Department of Medicine established a patient safety committee (PSC) and charged it with reviewing adverse events. (2) Cultural Change-PSC sponsors and participants work to promote a culture of collaboration, study, learning, and prevention versus a culture of blame. (3) Collaboration-The PSC includes chief residents and members from medical informatics, nursing, pharmacy, quality assurance, risk management, and utilization management. (4) Evolution-The duties of the PSC progressed from merely learning from adverse event reports to implementing patient safety and quality improvement projects. (5) Standardization-The PSC uses standard definitions and procedures when reviewing cases of adverse events, and when conducting patient safety and quality improvement projects.
  
  
  RESULTS
  (1) Developed an online adverse event reporting system, shortening the average report collection time by 2 days and increasing the number of adverse events reported. (2) Established a model for change using (a) safety rounds with residents, (b) e-mail safety alerts, and, in some cases, (c) decision alerts using electronic order entry. These changes in culture and capability led to improvements in care and improved financial results.
  
  
  CONCLUSIONS
  Senior management support of a culture of learning and prevention and an organizational structure that promotes collaboration has provided an environment in which patient safety initiatives can flourish by providing not only safer and higher quality patient care but also a positive financial return on investment.
authors: Patient Safety Committee, Department of Medicine, Rush University Medical Center, Chicago, IL 60612, USA. rich_odwazny@rush.edu
authors: Richard
authors: R
authors: Odwazny
authors: Scott
authors: S
authors: Hasler
authors: Richard
authors: R
authors: Abrams
authors: Robert
authors: R
authors: McNutt
mesh_terms: D020000:Decision Support Systems, Clinical; D006748:Hospital Departments / Q000592:standards*; D006801:Humans; D007388:Internal Medicine / Q000592:standards*; D019300:Medical Errors / Q000517:prevention & control*; D017146:Models, Organizational; D015279:Organizational Culture; D009936:Organizational Innovation; D010353:Patient Education as Topic; D010865:Pilot Projects; D017410:Practice Guidelines as Topic; D011367:Professional Staff Committees / Q000458:organization & administration*; D011785:Quality Assurance, Health Care / Q000379:methods*; D017751:Safety Management / Q000379:methods* / Q000458:organization & administration; D018571:Sentinel Surveillance; D014882:Water-Electrolyte Balance