Going an Extra Mile for Patient Safety
PSAT team members meet: Michael Mahler, M.D., Joan Lopes, R.N., Brian Cassmassi, M.D., Lucy Bermudez, R.N., Therese Cortez, R.N., Joann Wortham, R.N., Aki Tesfasilase, R.N., William George, M.D., Tonia Jones, Ph.D. (A complete list of team members noted below.)
The VA Greater Los Angeles (GLA) Healthcare System Patient Safety Advisory Team (PSAT) goes the extra mile to coordinate the evaluation, reporting and follow-up actions that involve patient safety and adverse events, encouraging staff members at all levels of the system to participate.
“What we are trying to do is to be as comprehensive as possible about collecting information surrounding incidents or concerns that could affect patient safety or quality of care,” said GLA Neurologist Michael Mahler, M.D., chair of the team.
The group acquires information from numerous sources. “For instance, a patient’s family might talk to the patient advocate,” he said. “And what might initially look like a complaint about customer service could include an underlying issue about quality of care. And the information will be forwarded to us.”
He also noted another example: A daily report that is developed by nursing services. “Every morning the report lists what has happened over night,” said Dr. Mahler, “but those who develop the list have little time to ask questions or go into great detail about problems that may have developed. That’s where our team comes in.”
Meeting at least twice weekly, team members analyze the reports and determine what actions might need to be taken.
“We might say, ‘You know what, the primary team needs to reevaluate this patient’s treatment plan,’ and not because of an error,” he continued. “We may have noticed something the primary team needs to do. For instance, a patient might be in a Community Living Center and we say, ‘Is this patient still meeting the criteria for a nursing home setting? Or is he getting too sick and need to be transferred?’ The goal being to correct problems before they happen, support our front-line clinicians and provide better care.”
Because the team’s approach to patient safety issues has been widely seen as a positive aspect of the GLA’s operations and culture, informal reporting has also been very important.
“For instance, a physician might email Dr. Mahler or myself and say ‘I think this case may merit a review,’ ” said Joan Lopes, the system’s chief of quality management. “We think these kinds of calls are important and often ask for additional information from those involved.”
She said the reaction to the team’s approach has enhanced the system’s culture of safety. “Even staff that are relatively new will call me or stop one of us in the hallway and say ‘Somebody told me I should talk to you about this thing I am concerned about,’ ” Lopes noted.
“I lived through a time when people did not tell you what happened or said they didn’t remember; didn’t see anything and so on,” she continued. “It’s very different now.
We have a long way to go, we’re not perfect by any means, but have had recent events where a variety of people have come to us and said, ‘I know this and that about it; what about this and what about that.’ All of which can help tie things together and create recommendations that we can and will do, rather than some ideal, pie-in-the-sky thing that sounds great on paper but will never get accomplished.”
Additional Information
Read the entire story in the March/April edition of TIPS
Team Members
Lucy Bermudez, R.N.
Michelle Buschmann Dhallin, R.N.
Feliza Calub, R.N.
Brian Cassmassi, M.D.
Joshua Chodosh, M.D.
Therese Cortez, R.N.
William George, M.D.
Tonia Jones, Ph.D.
Joan Lopes, R.N.
Michael Mahler, M.D.
Aki Tesfasilase, R.N.
Neil Shah, health systems specialist
Joann Wortham, R.N.
