Voluntary Reporting & QA
Improving Safety in Complex Healthcare Delivery Systems
It has long been recognized that even single reported events or errors are due most often to the convergence of multiple contributing factors. Identifying the true source or sources of a problem requires root cause analysis (RCA) to move beyond reflexive surface-level fixes that may not even address the true problem, or worse, have unintended consequences.
Daily Outreach to Residents, Monthly Updates to Division Quality Leads
In addition to our dedicated outreach with Department of Medicine residents, Division Quality Leads convene monthly at the Columbia Quality Assurance Meeting to present and update on individual cases and quality initiatives being conducted.
A Culture of Safety
Our reporting and outreach initiatives encourage an environment of Just Culture that shifts from a cycle of blame to a cycle of learning. Because multiple factors may be involved, simply blaming an individual will not address underlying factors, meaning the same error is likely to recur.
Our Safety Event Review Tool
We developed a comprehensive algorithm to facilitate Just CultureĀ and help guide fair and respectful reviews of reported events.
Download the Safety Event Review Tool