Christiana Care Health System: Safety Mentor Program

Excerpt

According to the Institute of Medicine, as many as 98,000 patients die each year because of preventable medical errors. The Christiana Care Health System is committed to eliminating preventable medical errors. A staff survey in 2001 showed that there were opportunities for improvement related to error reporting. Staff across the board felt they had responsibility for error prevention but viewed the error-reporting process as less than user friendly. Survey respondents also expressed fear of the consequences of being associated with an error. In 2003, the concept of a Safety Mentor program was first proposed during a focus group discussion. As conceived, the Safety Mentor would be an interdepartmental “ambassador” who could help staff navigate the system of error reporting, safe practices, and infection control. By May 2004, approximately 75 frontline staff had assumed this role. Safety Mentors now represent virtually all areas of the organization, including clinical and support departments. Through the Safety Mentor program’s additional efforts to identify barriers and implement best safety practices, Christiana Care has demonstrated a decrease in reported events with major outcomes and an increase in reported near-miss medication events that were corrected before they reached the patient. These trends reflect our efforts to provide reliable health care by detecting failures before they occur, thus mitigating harm to our patients. This increase in near-miss reporting allows us to place emphasis on learning and implementation of practice changes to improve safety. A Safety Mentor program can be implemented in a diverse range of health systems. It has proven to be effective in engaging frontline staff in patient safety efforts. This innovative program was reviewed by the Agency for Healthcare Research and Quality’s High-Reliability Network learning organization and found to be a promising practice.