Donna R. Meador, K-HEN Project Director

1. Kentucky Hospital Engagement Network Stories from the Other Side: when you are the dot on the run chart Donna R. Meador, K-HEN Project Director

2. Objectives: • Demonstrate the power of story-telling in patient safety and quality work • Discuss the difference that genuine patient and family engagement makes in an organization’s culture • Describe how adverse drug events can impact patients and their families

3. The Power of a Story We know the work we are doing is important, but how do we make it real to our staff? And sometimes to our leaders? Stories go way back, even before YouTube

4. Patient Safety Heroes

5. Adverse Drug Events

6. ADE’s continued “You can’t improve what you don’t measure.”

7. ADE’s cont’d. • Opioid Safety • Anticoagulation Management • Glycemic Management mine that data!

8. Errors happen even at “the best” • University of Minnesota Amplatz Children's Hospital

9. A story about Organization and Culture • (Sharon, can you imbed the organization and culture video in to this slide?)

10. Learnings • Errors can happen to anyone • Even at the “Best Places to Work” • Errors can be handled in many ways.

11. My best recommendations? • Open culture, staff free to report without fear of punishment • Errors need to be properly investigated, RCA, etc. to determine how to avoid in the future • Communication and disclosure to patient/family • Apology and remediation • Commitment to system improvement • Data tracking and performance evaluation • Education and training

12. Thank you! Questions?