Lessons Learned

1. Spreading Lessons Learned

Reporting systems alone do not bring change; nor does the completion of a root cause analysis (RCA). Usually, the only people who know about system and process failures are those involved in an incident. Valuable lessons from RCAs are not routinely shared across frontline staff and managers within the relative specialty area, let alone systemwide. The Agency for Healthcare Research and Quality’s (AHRQ) Culture of Safety Survey revealed that only 52 percent of respondents reported any feedback about changes that were put into place based on event reports.

To be successful in patient safety, risk managers must find ways to spread the lessons learned systemwide. A lesson learned can be defined as knowledge or understanding gained by experience. The experience can be positive (i.e., a best practice) or negative (i.e., a mishap or failure). A lesson must significantly impact operations and be factually correct and be applicable in that it identifies a specific design, process, or decision that reduces or eliminates potential failures, or reinforces a positive result.

As champions for an enterprise-wide culture of safety, risk managers must support the spread of lessons learned by encouraging open communication of safety issues, educating staff regarding patient safety principles, promoting safety as everyone’s responsibility, and identifying resource needs.

term to know

Lesson Learned

Knowledge or understanding gained by experience

2. Contributing to Safety and Learning Processes

Risk management can contribute to safety and learning processes by

• Building relationships with physicians and staff to gain their perspectives and including them in process improvement
• Using credible sources and case studies, such as from the Pennsylvania Patient Safety Advisory
• Celebrating successes regarding near-miss events, such as by taking your patient safety committee to the departments and awarding them a certificate, which will also put the committee more in touch with physicians and staff
• Disseminating information in a timely manner to those who will benefit from the information
• Discussing patient safety rounds, leader rounds, and patient safety committee
• Supporting a culture of safety

3. Communicating Successes and Lessons Learned

These techniques from ECRI Institute can help spread the word and communicate success and lessons learned:

• Use word-of-mouth feedback during multidisciplinary patient care rounds.
• Incorporate outcome data into a quarterly report to medical staff departments and hospital departments.
• Report results of quality benchmarks for the improvement project to the quality improvement committee.
• Create an Intranet-circulating banner displaying positive results, e.g., “Falls Reduction Project a Success! Rehab unit reduced the incidence of falls by 50 percent. Stop by Rehab and congratulate your colleagues.”
• Develop screen savers displaying success in graphs or tables, “before and after” pilot projects (e.g., reduction of central venous catheter infections).
• Take advantage of restroom “stall stories” (e.g., place attractive signs in staff and visitor restrooms highlighting the effectiveness of hand hygiene in reducing healthcare-associated infections).
• Place posters outlining “how we did it” on unit bulletin boards, e.g., implementation of a rapid response team to reduce cardiac arrests outside the ICU.
• Publish patient safety culture survey results in hospital newsletters.
• Involve executive leaders by scheduling periodic visits to units for support and encouragement.

Support

If you are struggling with a concept or terminology in the course, you may contact RiskManagementSupport@capella.edu for assistance.

If you are having technical issues, please contact learningcoach@sophia.org.