Oregon’s Top Patient Safety Lesson

Information that Oregon healthcare organizations contributed to the Patient Safety Reporting Program (PSRP) about adverse events and how they address them, highlights an essential element that must be in place before any efforts to make care safer can be successful—a culture of safety. Regardless of the type of event or the underlying causes, without first taking steps to create a culture of safety, well-intentioned patient safety improvement efforts are less effective and unsustainable.

The relationship between a culture of safety and effective patient safety programs has also been present in recent patient safety research. One clear example of this relationship was noted in a recent study, which found that the use of a quality measurement tool expressly designed to avoid blame was, in practice, experienced as a “blame allocation device.” Without a culture of safety, study participants could not use the tool to support their patient safety work, despite the intent and careful design of the tool.

To build an effective patient safety program and to tackle an ever-evolving range of safety issues, an organizational culture of safety is foundational to success.

What You Can Do

The Patient Safety Reporting Program’s 2018 Annual Report outlines the elements necessary for healthcare organizations to create a culture of safety. Years of research and collaboration tell us that a culture of safety starts with engaging leadership support, establishing a system for reporting and analyzing adverse events, and dedicating the necessary resources to it. Read the report to learn about the specific steps your facility can take to ensure a robust safety culture.

What You’ll Need

Patient Safety Reporting Program 2018 Annual Report
Oregon Patient Safety Commission
Read about all the lessons learned from Oregon’s Patient Safety Reporting Program and learn the core elements you need to create a culture of safety that can effectively prevent the risk of harm to your patients.

In Oregon, healthcare facilities have a resource for making care safer—the Oregon Patient Safety Commission’s Patient Safety Reporting Program (PSRP). PSRP is a non-punitive system designed to cultivate trust, inspire information sharing, and motivate quality improvement among healthcare organizations. Because healthcare is constantly changing and evolving, PSRP focuses on understanding and building Oregon’s capacity for learning from adverse events, which has the potential to serve all Oregonians.