Name
#43 MOSHing for Patient Safety - Enhancing Mitigation Effectiveness through Collaboration of Multi-Departmental Patient Safety Events
Speakers
Content Presented on Behalf of
DHA
Services/Agencies represented
Defense Health Agency (DHA), US Navy
Session Type
Posters
Room#/Location
Prince Georges Exhibit Hall A/B
Focus Areas/Topics
Policy/Management/Administrative, Trending/Hot Topics or Other not listed
Learning Outcomes
"Following this session, the attendee will be able to:"
1. Identify barriers to achieving intermediate and strong mitigation strategies using the standard patient safety event investigation process.
2. Discuss strategies for utilizing face-to-face collaboration to effectively increase patient safety event mitigation strength.
3. Identify secondary improvements to patient safety programs following MOSH implementation.
4. Discuss the positive impact of MOSH on the organization’s safety culture, specifically focusing on the frontline workforce.
1. Identify barriers to achieving intermediate and strong mitigation strategies using the standard patient safety event investigation process.
2. Discuss strategies for utilizing face-to-face collaboration to effectively increase patient safety event mitigation strength.
3. Identify secondary improvements to patient safety programs following MOSH implementation.
4. Discuss the positive impact of MOSH on the organization’s safety culture, specifically focusing on the frontline workforce.
Session Currently Live
Description
This A3 focused on achieving stronger mitigation strategies from multi-departmental patient safety events by substituting collaborative team meetings in lieu of the traditional online reporting process. Building a strong culture of safety is a critical step in eliminating preventable patient harm. Without a strong safety culture, a culture of blame and defensiveness emerges, including weak mitigation strategies for patient safety events that fail to protect future patients. Too often, patient safety investigations involving multiple departments fail to focus on contributing factors and mitigations, instead favoring defensiveness and a propensity to blame other departments. This tendency can be partially attributed to the siloed workflow of the JPSR investigative process where patient safety investigators provide feedback independent from other stakeholders. To overcome this tendency, U.S. Naval Hospital Guam instituted the Mitigation Opportunities for Safer Healthcare (MOSH) program. Within days of a triggering event, pertinent stakeholders gather at a MOSH session where team members reach a shared mental model of the event and develop collaborative mitigation strategies. In our six months of the MOSH program, we have experienced an increase in percentage of intermediate and strong mitigation solutions, reduced PSR closure times, and increased investigator and workforce satisfaction.
[This project was submitted via MTF-tasker as a breakout session, but as there has been no notification of acceptance/rejection, the poster format is being submitted as well. If the breakout session is accepted, the poster abstract will be deleted. Thank you!]