%0 Journal Article
%T Enabling Practice Leaders to Reduce Patient Harm through ¡°System-Base Practice and Practice-Based Learning and Improvement¡±
%A Ranjit Singh
%J Open Access Library Journal
%V 1
%N 8
%P 1-8
%@ 2333-9721
%D 2014
%I Open Access Library
%R 10.4236/oalib.1101101
%X Background: Healthcare organizations regularly face new challenges. Their
leaders must be adaptive through systematic approaches. These approaches must
meet three basic needs: 1) facilitation of workflow/process/task assessment and
improvement; 2) creation of high reliability organization; and 3) respect of
each practice as a special part of the total healthcare system. The US Institute
of Medicine has called for higher quality at lower cost through ¡°<i>leadership that fosters continuous learning</i>¡±.<i> </i>Retrospective methods are currently the
most commonly used. These reveal only the tip of the iceberg of the total harm.
The US Inspector General takes the view that the ¡°current methods of detection
of adverse events are inadequate¡±. Recommended Approach: An innovative <i>prospective</i> process is put forward. It fosters
empowerment and ownership, eventually leading to high reliability practices. Conclusion:
This approach is shown to be effective in measuring safety state in a practice
and reducing patient harm. Could this be the ¡°better way¡± that the Inspector
General is seeking? Our experience with this approach in the domains of
medication safety, falls safety, postoperative pain, and assessment of effects
of HIT introduction has demonstrated that it also promotes core competencies of
¡°<i>system-based practice</i> and <i>practice-based learning and improvement</i>¡±<i> </i>in staff.
%K Harm
%K Leadership
%K Practice
%K Reliability
%K Safety
%K System
%U http://www.oalib.com/paper/3129819