Medical Staff News Safety is a Team Sport: The Root Cause Analysis (RCA) Process
In December 2021, the Department of Patient Safety and Risk Management made the decision to modify the RCA process to align with industry best practice. Transparency in RCAs are critical to the effective learning and information sharing necessary to prevent future safety events and protect our patients. Specifically, RCAs will have a significantly reduced number of guest participants with the intent to create an encouraging environment for small group discussion and brainstorming. The participants will include primarily staff members directly involved in the event and their leadership, with ad hoc participants invited based on the specific needs of the RCA.
These changes will in no way diminish the importance of the RCA or the mandatory participation requirement. Robust participation remains a critical component to the RCA process and ultimately to Harris Health System’s journey to zero harm. We will continue to expect guests and leaders to make the RCA a scheduling priority.
The objectives of the RCA will focus on establishing and defining the presence of care gaps, identifying contributing factors and root cause(s), as well as attempting to identify an immediate action plan for prevention or mitigation of future error. The Department of Patient Safety and Risk Management will continue to maintain the confidentiality of the RCA with the focus being to improve the overall quality of care and safety that Harris Health System delivers to our patients. The patient safety team will continue to solicit feedback from participants to improve the RCA process. For any questions, please contact your pavilion patient safety director.
A High Reliability Organization Principle
For patient safety champions, the Reluctance to Simplify HRO principle means that we investigate, explore and get to the bottom of any and all patient safety-related events.
Patient safety champions lead the way and engage their teams and leadership to be detailed-oriented, action-driven and open to different opinions and explanations for mishaps in order to reach the best solution for the sake and safety of our patients.
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Debunking Myths on HIV Risks: A targeted strategy to challenge perceptions of low HIV, HCV, STI risks among African American women
By Dr. Mandy Hill at Harris Health System’s Lyndon B. Johnson Hospital
Background/Problem: Sexually-active Black women in the U.S. are more at risk of becoming HIV positive than woman in any other race. In response to researchers calling for public health interventions that are capable of preventing HIV and STI transmission, we launched the first video log (VLOG)-based pilot HIV prevention intervention for Black women who acknowledged recent condomless sexual activity during an emergency department (ED) visit.
Proposed Study: Using a prospective, comparative effectiveness, randomized clinical trial study design, we compared the preliminary effectiveness of two educational intervention strategies at increasing knowledge on how HIV and sexually transmitted infections are transmitted. Eligible participants were randomized to one of two experimental arms: 1) an interactive gaming education-based strategy or 2) a storytelling education-based strategy. Both strategies used a video log (vlog) format displayed on a tablet device.
Outcomes:Findings suggest that although VLOGs may resonate with African American or Black women, this intervention strategy alone likely does not have the potential to dispel myths on HIV transmission, raise awareness of the HIV/STI risks that accompany condomless sex, or provide facts to inform healthy sexual decision-making.
Potential Clinical Impact: Vlogging as a behavioral intervention strategy has potential and required further study to explore the potential health benefits of this approach. Utility of vlogging as a brief intervention strategy has potential to expand the utility of social media as a medium for brief interventions aimed at HIV/STI prevention that can be feasibly be integrated into the care cascade of an emergency department setting while extending access to the intervention across diverse at-risk populations.
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