QUESTION 1
Introduction
Morath drove and initiated the Patient Safety Initiative at Children’s Hospital and Clinics by transforming mindsets and culture within the hospital. Key initiatives implemented by her included (a) Introduction of a Blameless Patient Safety Reporting System (b) Conducting Focus Groups and (c) Setting up of Patient Safety Steering Committee.
Building Block 1: A supportive learning environment (key activities implemented, key challenges and effectiveness of endeavor)
1.1 Psychological Safety
1.1.1 Blameless Patient Safety Reporting System
Morath introduced a Blameless Patient Safety Reporting System for recording medical errors, where employees were allowed to communicate confidentially and anonymously about medical accidents without penalty. She added a category to the existing patient safety report to allow employees to describe and comment on the incidents.
Challenges
o To change people’s ingrained mindset towards a medical accident; from one that is penalty-centric to one that is a learning-centric.
o To convince employees that owning up to a mistake would not backfire.
Effectiveness
o The system indeed encouraged, the employees to be more forthcoming in sharing their mistakes.
o The system assumed that errors occurred due to drawbacks in processes rather than incompetence of staff. However, besides process drawbacks, human errors could also be the cause. As such, it was difficult to hold any employee accountable and responsible for his or her negligence. No consequences for poor performance might lead to mistakes being repeated.
1.1.2 Common Language
She introduced a common language which fostered an environment where ever ...