TRANSFORM-ing Patient Safety Culture: A Universal Imperative

Excerpt

The importance of patient safety has been well established in the United States, inspired by the oft-cited Institute of Medicine reports “To Err is Human” and “Crossing the Quality Chasm.”1 ^, 2 The World Health Organization (WHO) has since broadened the quest to the international scale, establishing the WHO Patient Safety Programme in 2004.3 A core component of this movement, which has been influenced by other industries, including those focused on preventing bad outcomes in high-risk and complex environments, is the establishment of a culture of safety. In this issue of JGIM, Braddock et al. describe a bundle of interventions focused on improving safety culture in the clinical microsystem of the hospital inpatient unit.4 The project, referred to as “TRANSFORM Patient Safety,” consists of the identification of patient safety champions, establishment of a patient safety working group, and introduction of ongoing incident debriefings, patient safety interdisciplinary case conferences, in situ simulation, and a teamwork performance award. TRANSFORM “bundles” successful interventions described in prior literature while, importantly, focusing on the clinical microsystems (nursing units) rather than the larger hospital or system level. Although this project was conducted in a challenging inpatient teaching environment, it still manages to address most of the components that the Agency for Healthcare Research and Quality (AHRQ) has described as critical to developing a culture of safety.5 …