Year: 2025
Type: article
Abstract: Background: Safety event reporting plays an important role in improving patient safety. The US Department of Veterans Affairs has focused on minimizing or eliminating harm to patients. Observations: The patient safety (PS) and high reliability organization (HRO) teams at the Central Texas Veterans Health Care System (CTVHCS) developed an education model that integrates the Joint Patient Safety Reporting System (JPSR) into huddles. JPSR Huddle Cards provide frontline staff and management with guidance on the purpose of the JPSR, the difference between an adverse event and a near miss, what root causes are, the lifespan of a JPSR, how to celebrate reporting, and key fact checks. Six cards were presented to staff (1 per week) during morning safety huddles to support the CTVHCS journey to high reliability. Participants completed a survey on safety before and after receiving the cards. Conclusions: Posttest scores were consistently higher than pretest scores, with an average increase of around 2 standard deviations across all questions.
Source: Federal Practitioner
DOI: 10.12788/fp.0597
Author: Michael Finch
Institution: Central Texas Veterans Health Care System
Language: English
Subfield: Emergency Medical Services
Field: Health Professions
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4414155487