Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic

In the midst of a crisis, monitoring patient safety and quality concerns is of utmost importance, particularly if attention paid to monitoring is diverted by other operational needs. The emergence of novel COVID-19 virus emerged new patient safety concerns. In an effort to help organizations respond rapidly to safety concerns, we describe a close to real-time process used to monitor, escalate, and resolve concerns submitted to the patient safety event reporting system of an academic health system.

Latent risk assessment tool for health care leaders

Efforts to improve quality of care and patient safety have concentrated on provider practice and frontline care processes. Little attention has focused on understanding the role that leadership decisions play in creating risk within a health care system. The framework and tool described in this article builds on Reason's construct of latent organizational failure, by assessing the latent risks of leadership decisions, and identifying appropriate mitigation strategies before the implementation of a change. Stakeholders who will be involved in or impacted by the change are engaged in the assessment to more thoroughly explore both technical and cultural risks.