Keeping patients safe: Meet a team of patient safety champions

The Patient Safety Event Team, from L-R: Rose Ramey, Joel Kilpatrick, Jeremy Gluskin and Karen Conlin.

When patients come to Michigan Medicine seeking treatment for an injury or illness, their safety is a top priority as faculty and staff strive to provide the highest quality care.

However, health care is a complex industry susceptible to both system issues and human error. When an event or circumstance takes place which may have resulted, or did result, in unnecessary harm to a patient while under the organization’s care, it is important to learn about the event and fix the system or process issues.

“Our main goal will always be to eliminate preventable harm for our patients, but we also recognize that we work in a very fast-paced, complex environment,” said Laura Lamps, M.D., patient safety officer for Michigan Medicine. “Therefore, it is equally important to have a strong team in place who can review adverse events when they do occur and work with partners across the organization to develop systematic changes that can prevent these mistakes from happening in the future.”

The team in charge of reviewing events that occur at Michigan Medicine is the Patient Safety Event Team (PSET). This team is made up of four patient safety specialists who all have clinical backgrounds in nursing. Team members are Karen Conlin, R.N., Jeremy Gluskin, R.N., Joel Kilpatrick, R.N., and Rose Ramey, R.N.

But what role does PSET play when unexpected outcomes occur, and how do they investigate and analyze patient harm events? Headlines recently sat down with the team to find out more.

Definition of a patient safety event

A patient safety event is an incident or condition that results or could result in harm to a patient. It can be the result of a defective system or process design, a system breakdown, equipment failure, human error or a combination of these things.

A no-harm or “near miss” event is when an incident occurs that did not result in harm to a patient but had the potential to cause harm. The organization refers to these as “good catches,” as they catch the problem before it reaches the patient.

Reporting of safety events

When a patient safety event or near miss occurs, employees are strongly encouraged to submit a Patient Safety Event report using this form. Every report submitted is reviewed by members of the event team to determine if a review is necessary and if so, what type of review.

“Every morning, two patient safety specialists review all of the event reports that were submitted the previous day,” said Ramey. “We always have two team members read the reports to be sure no event that requires further investigation is missed.”

Each event report is then classified by the team based on several factors including severity, frequency and level of harm to the patient.

“Our role is to look at the circumstances that led to an event and determine if there is a system or process issue that led to the problem,” said Kilpatrick. “If the level of harm is severe enough or there are an increased number of similar incidents with the potential for harm, we will recommend that the event be sent to the Safety Event Triage Team (SETT).”

SETT is a committee of clinical providers who use their expertise to make recommendations on what type of review events should receive, and how they should be classified regarding level of harm — ensuring that the Office of Patient Safety allocates resources as wisely as possible for event reviews.

Patient event reviews  

If SETT recommends conducting a full event review, a member of PSET is assigned to lead a multidisciplinary team of representatives who use event mapping, cause-and-effect diagramming and other techniques to determine the root cause of the harm event. Following that, an action plan is developed, along with metrics for assessing the items on the plan, and specific providers assigned to the tasks in the plan. Each review requires about 40 hours of PSET time from start to finish.

The main focus of PSET and the event review process is to identify system gaps that can be addressed to strengthen the institutional systems and better support employees on the front lines of patient care.

“Investigation of a safety report is really driven by curiosity,” said Gluskin. “Each of us look at adverse patient events and work to uncover the system or process gaps that allowed something to go wrong. We want to understand what happened and how it can be prevented from happening again.”

Keeping patients safe at Michigan Medicine takes more than just the work of the Patient Safety Event Team, however.

“We honestly couldn’t do the work that we do without our clinical partners – our colleagues at the patient’s bedside who speak up when something isn’t working right,” said Conlin. “It is through this partnering that safer systems and processes are established.”

The Patient Safety Event Team would like to thank those who take the time to report a harm or near miss event and the amazing work of the clinical and operational experts who participate in event reviews.