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Make no mistake, error prevention deadline approaches

Published on Monday, June 6, 2016

By: Ruth Cummins

The Medical Center's 10,000-plus employees are in the final stretch of error prevention training, with a December 2016 finish in sight.

The 2.5-hour training sessions are mandatory - and they're already impacting the prevention of events that result in harm to patients or to any of the 25,000 people who daily teem in and out of campus.

“I'm seeing more people raising their hands, willing to take part in initiatives such as hand hygiene and reducing infections,” said Shannon Wentz, administrator in the Office of Chief Medical Officer Dr. Michael Henderson and one of the 30 people across the organization who volunteer as trainers.

Only about 2,500 employees have yet to enroll in training designed to help them keep their individual workplace safe and free of errors or other actions that can result in harm to patients. It's part of a cultural evolution and shift in thinking designed to prevent harm from happening in the first place.

That's being achieved by creation of a no-fear zone in which all are free to ask questions or voice concerns regarding patient safety -- and where employees welcome being questioned by others.

We all play a role in reducing health-related errors at UMMC,” said DIS web content coordinator Susan O'Bryan, who completed her training June 2. “This course reiterates that no matter what department, we are in this together. It's a good reminder to use what we have - common sense, communication and dedication to 'do no harm.'''

Henderson's office is making progress not just in getting more employees engaged and trained, but in tracking whether the training is playing a role in both prevention of patient harm and the comfort level of employees wanting to report areas of concern. That's being achieved in part through the Medical Center's I Care (I Communicate At Risk Events) electronic reporting system that makes it quick and easy for any employee to electronically pass on information on unsafe events or close calls.

Employees can make a report by clicking on “Healthcare” in the top bar on the Intranet home page, then going alphabetically to I Care Report to fill out a short form. Also, the Medical Center's computers have a desktop “I Care Report” icon. Reports can be anonymous, although employees are encouraged to identify themselves in case there are follow-up questions.

There's a definite uptick in reporting potential and actual errors, Wentz said. In June 2015, close to 450 reports were filed. In May of this year, the number stood closer to 600.


“We are seeing more transparent reporting via iCare, meaning that people aren't afraid that they are 'telling on' someone, and they aren't afraid of punitive action,” Wentz said.

The error prevention training program kicked off in September 2014. To sign up, log into HealthStream from the UMMC Intranet. Select Catalog, then click on the Patient Safety folder. Select Error Prevention Training on the right side of the page, then register for a class.

Classes aim to empower employees to take a fresh look at decreasing errors that can lead to patient harm, and to question whether a particular decision or action might adversely impact a patient. They are learning what safety means to their particular work area, and how they can use tools from training to put safety first.

The training emphasizes employee engagement and holding each other accountable, Henderson said.

“We need to be willing to pause and ask the questions, and speak up and say, 'This doesn't feel right,'” he said. “If someone raises a concern, treat it seriously.”