ahrq-partnersAn impact case study, published by the Agency for Healthcare Research & Quality, illustrates how St. Jude Children’s Research Hospital in Memphis, TN used data obtained through implementation of AHRQ’s Hospital Survey on Patient Safety Culture to develop quality interventions and facilitate improvement in areas including patient safety event reporting.  St. Jude has distributed the survey three times since its 2009 adoption of the trusted tool for the purpose of gaining a clearer understanding of its organizational culture.  

Response rates, among St. Jude’s approximately 1,000 patient care employees, who were given the opportunity to complete the survey, have ranged from 46 to 54 percent. Results from St. Jude’s initial distribution of the survey caused the hospital to place high priority on improving communication surrounding the occurrence of patient safety events. Simple modifications,  like added summaries within the hospital’s voluntary event reporting system, significantly increased discussion about specific events. Now, more and more, instead of blaming each other when an event occurs, staff members talk to each other about how they can work together to prevent errors and near misses. 

Consequently, when the survey was administered in 20011, the number of employees who responded positively regarding communication and feedback surrounding safety events made a significant jump from 59 percent to 76 percent. In addition, survey results also prompted St. Jude to modify its customized electronic event reporting system by adding a text box in which event reporters can provide suggestions for improving care delivery. The hospital also streamlined its reporting tool with the aim of allowing a user to report an event in only 2 minutes or less. 

To learn more about how St. Jude has utilized AHRQ’s Hospital Survey on Patient Safety Culture to improve event reporting and to design other interventions that address issues including transitions of care and second victims, click here.