title: The association between event learning and continuous quality improvement programs and culture of patient safety.
abstract: OBJECTIVE
  To present our approach and results from our quality and safety program and to report their possible impact on our culture of patient safety.
  
  
  METHODS
  We created an event learning system (termed a "good catch" program) and encouraged staff to report any quality or safety concerns in real time. Events were analyzed to assess the utility of safety barriers. A formal continuous quality improvement program was created to address these reported events and make improvements. Data on perceptions of the culture of patient safety were collected using the Agency for Health Care Research and Quality survey administered before, during, and after the initiatives.
  
  
  RESULTS
  Of 560 good catches reported, 367 could be ascribed to a specific step on our process map. The calculated utility of safety barriers was highest for those embedded into the pretreatment quality assurance checks performed by physicists and dosimetrists (utility score 0.53; 93 of 174) and routine checks done by therapists on the initial day of therapy. Therapists and physicists reported the highest number of good catches (24% each). Sixty-four percent of events were caused by performance issues (eg, not following standardized processes, including suboptimal communications). Of 31 initiated formal improvement events, 26 were successfully implemented and sustained, 4 were discontinued, and 1 was not implemented. Most of the continuous quality improvement program was conducted by nurses (14) and therapists (7). Percentages of positive responses in the patient safety culture survey appear to have increased on all dimensions (p < .05).
  
  
  CONCLUSIONS
  Results suggest that event learning and continuous quality improvement programs can be successfully implemented and that there are contemporaneous improvements in the culture of safety.
authors.affiliation: Division of Healthcare Engineering, Radiation Oncology Department, University of North Carolina, Chapel Hill, North Carolina. Electronic address: lmazur@med.unc.edu.
authors.forename: Lukasz
authors.initials: L
authors.lastname: Mazur
authors.affiliation: Division of Healthcare Engineering, Radiation Oncology Department, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Bhishamjit
authors.initials: B
authors.lastname: Chera
authors.affiliation: Division of Healthcare Engineering, Radiation Oncology Department, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Prithima
authors.initials: P
authors.lastname: Mosaly
authors.affiliation: Division of Healthcare Engineering, Radiation Oncology Department, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Kinley
authors.initials: K
authors.lastname: Taylor
authors.affiliation: Division of Healthcare Engineering, Radiation Oncology Department, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Gregg
authors.initials: G
authors.lastname: Tracton
authors.affiliation: Division of Healthcare Engineering, Radiation Oncology Department, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Kendra
authors.initials: K
authors.lastname: Johnson
authors.affiliation: Division of Healthcare Engineering, Radiation Oncology Department, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Comitz
authors.affiliation: Division of Healthcare Engineering, Radiation Oncology Department, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Robert
authors.initials: R
authors.lastname: Adams
authors.affiliation: The Edward P. Fitts Department of Industrial and Systems Engineering-North Carolina State University, Raleigh, North Carolina.
authors.forename: Pegah
authors.initials: P
authors.lastname: Pooya
authors.affiliation: The Edward P. Fitts Department of Industrial and Systems Engineering-North Carolina State University, Raleigh, North Carolina.
authors.forename: Julie
authors.initials: J
authors.lastname: Ivy
authors.affiliation: Division of Healthcare Engineering, Radiation Oncology Department, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: John
authors.initials: J
authors.lastname: Rockwell
authors.affiliation: Division of Healthcare Engineering, Radiation Oncology Department, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Lawrence B
authors.initials: LB
authors.lastname: Marks
mesh_terms: D006801:Humans; D061214:Patient Safety / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000592:standards*; D058996:Quality Improvement / Q000592:standards*; D017751:Safety Management / Q000592:standards*