Serious safety events: Getting to Zero™

To advance the goal of Getting to Zero and eliminating preventable harm, ASHRM is providing guidance for defining, investigating, and measuring serious safety events. The first step in this process is the recommendation for a common and standardized definition. A common definition for a serious safety event facilitates timely detection, rapid action, and future prevention. This paper outlines that definition, provides a skill‐based model for investigation, and explains a clear plan for how to conduct the investigation. A measurement system is described to determine the frequency of SSEs and comparison methods to determine events prevented, potential lives saved, and methods to demonstrate financial loss control. These methods and approach are consistent with ASHRM's core values and mission, which is safe and trusted healthcare.     

Professional collaboration to achieve FASHRM and DFASHRM recognition

Members of the American Society for Healthcare Risk Management (ASHRM) are undeniably talented. They also share a spirit of volunteerism. Two ASHRM committees are fostering further member collaboration to provide individual growth, enhance educational offerings for members, and strengthen the organization's journal. Though 26% of ASHRM members have attained the CPHRM credential, only 2.5% of ASHRM members have attained a fellow designation. Primary barriers to attaining a fellow designation are the requirements for continuing education and contributions to the risk management field. The organization's Journal Editorial Review Board, in concert with its Annual Conference & Exhibition Committee, encourages members to explore opportunities to write for the Journal, speak at the annual conference, and attain one of the organization's professional designations. In addition, the Barton Certificate Program in Healthcare Risk Management promotes professional development with sessions taught on this topic for new and experienced risk managers.     

The silent organizational pathology of insidious intimidation

While organizations are valiantly striving to address acts of disruption among physicians and nurses, a silent and yet equally disruptive pathology is spreading through the veins of the organization. This behavior is found among all ranks and responsibilities, from the C‐suite to the housekeeping staff. It occurs daily and is rarely reported. It continues because its nature is such that it is difficult to measure, the victims often feel helpless, and the perpetrators are often those in positions that are not normally perceived to be as essential to the flow of patient care. Nonetheless, this insidious intimidation chills communication, reduces morale, and ultimately harms patients. Organizations that desire a culture of safety and comfort must address this behavior through individual coaching, education of all staff, a willingness to tackle system frustrations that amplify and perpetuate the behavior, and establish processes for dealing fairly and firmly with the behavior.     

The timing of early resolution: Working at the patient's pace

In recent years, risk managers have been charged with educating providers who need to know how to communicate to a patient that an unanticipated or adverse event has occurred. Much has been written about the elements that should be part of a disclosure conversation: who should be involved, what should be said and when it should be said. Patients have acknowledged their desire to have early, and complete, information where possible. However, what is lacking is an understanding of what happens after the initial disclosure conversation, when the time comes to discuss accommodation or compensation with the patient or family. This article will look at the post‐disclosure status of the patient or family, the steps of the grieving process, and the mechanisms for both the risk manager and the provider to successfully bring closure to the event.     

Take the Opportunity

As you read this, we will be approaching our annual conference. I am so excited! We have been changing our annual conference over the last 3 to 4 years in order to provide our members with a better product/experience. Everyone who looked at our conference was surprised at how successful it was, but we wanted to make it even better for the members. And I think we have succeeded—but we need to keep making it better every year.     

Where should patient safety be installed?

The structure of an organization is important, and structure has a profound influence on the way people work and what gets done. 1 Where work units and individuals in an organization are placed, to whom they report, and with whom they are grouped signals power, prestige, and privilege. It also divides workers into groups with common interests and motivations. The question is, where should patient safety be placed in a health care organization? Such a question can be answered only within a framework of understanding that gives a clear definition to patient safety. We define safety, as do safety professionals from other industries, as the reduction of risk. 2 , 3 This definition is also in concert with the risk management model that identifies claims management, risk financing, and loss control as its foundational triad.