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Article Recommends Role of “Patient Safety Professional” to Increase Patient Safety


While checklists and reminders constitute the two most widely-recommended prevention strategies for common patient safety problems in the hospital, there may be inherent barriers that limit their utility. For example, studies argue that checklists used alone may fall prey to the same fate as guidelines – often unused even when well-conceived. Also, computer-based reminders require computerized order entry or electronic medical record systems, which remain limited outside the VA healthcare system. This article recommends consideration of a new type of clinical role in the hospital setting – the Patient Safety Professional (PSP) – to ensure that each patient receives individualized prevention strategies to minimize the hazards of hospitalization.

Given the current workloads of inpatient physicians and bedside nurses, it may be impractical to assume that they could consistently ensure that their patients receive the necessary methods to prevent hospital-acquired complications. Therefore, authors suggest the PSP be an advanced practice registered nurse, who would: 1) assess assigned patients for hospital-acquired complications (e.g., pressure ulcers, falls, pain) following explicit protocols relevant to a short list of safety targets; 2) prioritize identified complications based on morbidity, mortality, and hospital costs; and 3) develop and implement plans to decrease hospital-acquired complications, in consultation with physicians and staff nurses. The PSP might also provide additional benefits to the organization, i.e., he/she could serve as an educational resource or consultant to other clinicians and take responsibility for staying up to date on new advances and recommendations in the area of patient safety.

The authors recently hired a PSP to work at one VA hospital and further describe ? through vignettes ? her specific duties. To their knowledge, this is the first such position in any hospital in North America. The authors suggest that the roll-out, benefits, and costs of PSPs be carefully evaluated before widespread dissemination is considered.

PubMed Logo Saint S, Krein S, Manojlovich M, et al. Introducing the patient safety professional: Why, what, who, how, and where? Journal of Patient Safety September 8, 2011;e-pub ahead of print.

Drs. Saint and Krein are part of HSR&D’s Center for Clinical Management Research in Ann Arbor, MI.

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What are HSR&D Publication Briefs?

HSR&D requires notification by HSR&D-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR&D and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR&D based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR&D published articles. Visit the HSR&D citations database for a complete listing of HSR&D articles and presentations.