The southern california perinatal patient safety project.

By Jean Sandoval, RN, MSN Janice McDonald, RN, MBA Suzanne Graham, RN, PhD The Northern California Perinatal Patient Safety Project (PPSP) won the Lawrence Patient Safety New Project Award in 2004 (See “The Perinatal Patient Safety Project: New Can Be Great!” in The Permanente Journal 2005 Winter;9(1):25-7 and “Perinatal Patient Safety Project” in The Permanente Journal 2005 Spring;9(2):28-33). With the purpose to create high-reliability perinatal units through the use of human factors, techniques and systems improvements, the project borrowed from the United States Navy, NASA, and similar organizations that operate highly complex systems with few errors over long periods of time. Using the precepts of the “Four As of Adoption” (see “Practical Steps for Practice Transfer” in The Permanente Journal 2005 Fall;9(4):501), Southern California began implementation of PPSP in November 2003 at the Riverside Medical Center by administering the Safety Attitude Questionnaire (SAQ) to their Perinatal staff and physicians and initiated their PPSP Steering Committee to begin the planning process. The other nine Medical Centers began cyclical implementation in 2004. The purpose of the Southern California PPSP was to: decrease human error and identify patient care systems in need of improvement; create a safe culture; develop a high-reliability perinatal unit; and apply a “Just Culture” environment to create a safe environment for team members. The project included training in team briefings/communication, assertion, error detection, and situational awareness to include identification of “red flags.” A project tool kit was developed by the Southern California Regional PPSP project managers that described the core elements and was utilized by the medical centers during their start-up and throughout their planning meetings. This tool kit is now available from the National Risk Management Program Office (available at: http://kpnet.kp.org/qs/nrm/ PPSP3/toolkit.htm) or the Southern California Project clinical contributions