reply to 2 students using 130 words or more towards each student and ADD a direct question to each reply. Ensure each name is with its corresponding reply
1st Student Melissa Lezama
The Patient Safety Alert (PSA) System was implemented to identify any patient safety concern that was life-threatening. However, when it initially began, quality incident reports (QIR) were already in place at the hospital for reporting circumstances that provided less-than quality care to patients. Therefore, when the PSA system was first pitched to the medical staff, much confusion existed about which situations should be PSAs and which should be QIRs. Eventually, executive leadership eliminated QIRs altogether and empowered staff to voice any concerns through the PSA system. The involvement of top leadership sent the message to staff that the PSA system would be taken seriously and all inputs would be reviewed and valued. The system put safety at the forefront of the Virginia Mason mission.
The implementation of the PSA system is critical to continuous process improvement because it provides an opportunity for all staff, in every department and at every level, to exercise their mission of safety. Additionally it utilizes input from a diverse collection of minds, thus broadening the perspectives that leadership is considering. Overall the PSA system has increased standardization, specifically in preoperational set-up procedures, which decrease the risk of mistakes. It has fostered a culture of slowing down to prevent haphazard processes, and reminds staff of the risks that their patients are exposed to every day.
Kenney, C. (2010). Transforming Healthcare: Virginia Mason Medical Center’s Pursuit of the
Perfect Patient Experience. Productivity Press.
2nd Student
The story of Mrs. Mary McClinton walks us through a pivotal moment in the change of culture for Virginia Mason. The tragedy of Mrs. McClinton’s case highlights a system error. Too often, individuals are blamed and mistakes are left to happen again. Virginia Mason recognized a system error and went about creating a culture of safety. Discuss the evolution of the PSA System and its importance.
The patient safety alert system (PSA) is a system known in Virginia Mason as a stop the line call. For the first couple of years, using the PSA system, Virginia Mason struggled to define the severity of the situations and medical errors that would categorize into the PSA system. After a couple of years they decided to categorize the PSA’s into three different colors once they eliminated the QIR category in 2005 (Kenney & Berwick, 2010). The three colors were red, orange, and yellow. Red was the most severe cases, and yellow was the least severe.
The PSAs eventually evolved once the staff noticed the importance and the innovation behind them. The staff noticed that the PSA system was a pivotal system that was not only saving lives but was an honest system to report situations and not just get penalized over mistakes. These mistakes were used more as learning lessons to the entire medical staff. For Mrs. McClinton’s family to come to one the PSA award ceremony that was in honor of her was amazing. Her family was able to witnessed the change that took place throughout the years after her passing. The mistake occurred during her death was not in vein. Not only did the mistake lead to change at Virginia Mason but other hospitals followed suite with changing the surgery prep table and solution set up.
Within the first two years of the reinvented PSA system, at least 1/3 of employees had reported a PSA. When employees noticed a quick response to their PSA reports, they continued to report the PSAs. In the evolution of the PSA system, Red PSAs have turned to needing to be reviewed by the board. Malpractice suites declined consistently once the PSA system continued to evolve (Kenney & Berwick, 2010). During the PSA award dedication ceremony more than 300 staff members of Virginia Mason raised their hand that they had filed a PSA. This means that so many policies, and procedures were evolved for the safety of patients thanks to the PSA system.
References:
Kenney, Charles, and Mason Clinic, Virginia. Transforming Health Care : Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience, Productivity Press, 2010. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=665590. Created from apus on 2022-10-23 21:19:49.
