The era of patient safety was ushered into the medical field with the Institute of Medicine’s publication “To Err is Human” in 1999.[1] This seminal report brought to light the significance of medical errors as a cause of death and proposed novel strategies for mitigating or avoiding adverse events due to errors. The overarching theme—that individual practice results in error more frequently than team-based care—aimed to show that medical errors could be reduced by improving systems rather than by placing blame on individuals. Using these principles, OB/GYN hospitalists can develop skills and promote practices to drive safety throughout their hospital systems. Opportunities for hospitalists to affect patient safety range from participating in analytic processes such as Root Cause Analysis and Failure Mode and Effect Analysis, to developing and implementing tools that reduce variation such as bundles, checklists, and protocols. OB/GYN hospitalists should understand, support, and promote these and other practices that are foundational to high reliability organizations.

Knowledge

OB/GYN hospitalists should be able to:

• Define patient safety.
• Describe the various types of patient safety errors.
• Distinguish between errors and violations.
• Describe how “normalization of deviation” can facilitate error.
• Explain the link between Normal Accident Theory, complexity, and error.
• Differentiate among harm, preventable harm, and near miss.
• Define the components of a safety culture.
• Define a high reliability organization.
• Define the foundation of mindfulness.
• List tools that help to reduce variation in care.
• Describe the relationships among a just culture, trust, and the components of a safety culture.
• Describe the relationship between a safety culture and a high reliability organization.

Skills

OB/GYN hospitalists should be able to:

• Identify the risk management personnel in the hospital system.
• Lead, coordinate, and/or participate in analytic processes such as Root Cause Analysis and Failure Modes and Effects Analysis.
• Develop effective checklists, protocols, and bundles.
• Apply the Just Culture Algorithm^TM to ensure a safety culture.
• Enter near misses and other patient safety concerns into hospital reporting systems.

Self-Awareness and Collaborative Attitudes

OB/GYN hospitalists should be able to:

• Apply a multidisciplinary approach when conducting event analysis.
• Facilitate a flexible culture with deference to expertise through example.
• Facilitate self-reporting of errors through example.

System Organization and Improvement

OB/GYN hospitalists should be able to:

• Drive patient safety by anticipating and containing errors.
• Lead, coordinate, and/or participate in patient safety efforts across multiple levels of health care and across multidisciplinary teams.
• Ensure that effective quality assessment performance improvement processes are in place for reporting risk or adverse events.
• Establish patient safety metrics that are modifiable and can lead to organizational improvement.
• Engage in or lead safety initiatives such as simulation and TeamSTEPPS ®.
• Participate in ongoing education regarding patient safety practices, risk management, communication, and organizational improvement.

References