Nursing Innovations in Patient Safety

 

Organization	The University of Texas Center of Excellence for Patient Safety Research and Practice and The Institute for Healthcare Excellence at University of Texan M.D. Anderson Cancer Center
Location	Houston, TX
Date of Implementation	July 2005
Nurse Leader	Debora Simmons, RN, MSN, CCRN, CCNS, Senior Clinical Quality Improvement Analyst, Institute for Healthcare Excellence, The University of Texas M.D. Anderson Cancer Center
Project Team	Susan Distefano, RN, MSN, CNAA, BC, Senior Vice President of Patient Care Services and Chief Nursing Officer at Texas Children's Hospital, Barbara Summers, PhD, RN, Vice President and Chief Nursing Officer at University of Texas M.D. Anderson Cancer Center, Rosemary Luquire PhD, RN, CNAA, FAAN, Senior Vice President, Patient Care and Chief Quality Officer, St. Luke's Episcopal Health Center, Peg Reiter, PhD, RN, Director of Patient Safety, St. Luke's Episcopal Health Center, Sharon Martin, Primary Investigator, Vice President of Quality Management, University of Texas M.D. Anderson Cancer Center, Gwen Sherwood, RN, PhD, FAAN, Professior and Executive Dean at University of Texas Houston School of Nursing, Eric Thomas, MD, MPH, Primary Investigator, University of Texas Center of Excellence for Patient Safety Research and Practice, Mary Beth Thomas, RN, MSN, Director of Nursing Practice and Education, Texas Board of Nurse Examiners
Project Title	Healthcare Alliance Safety Partnership
Type of Innovation	Organizational Culture
Innovation	A research initiative to understand system influences on errors made by nurses and resolve those issues within a non punitive environment.  HASP provides an alternative reporting and review process for nurses wishing to self-report errors and has been approved by the Board of Nurse Examiners for the State of Texas.  First, non-punitive error reporting system in partnership with a nursing board in the nation.
Outcome	Joint review of error reports by a member of the Board of Nurse Examiners, Chief Nursing Officer, and chair of peer review committee. Identification of systems and human performance factors in error reports using a modified Eindhoven classification and human factors investigation. Prescriptive recommendations to prevent the error from recurring with a response from the institution that addresses those factors. Immunity from Board action and no record on license with completion of program.