Federal Employee Health Benefits

Kaiser Permanente California Patient Safety Initiatives

We have a Director for Patient Safety that oversees the program across Northern and Southern California. This position is overseen by the Vice President of Quality in Northern California and by the Vice President for Quality and Risk Management in Southern California. Nationally, the position is overseen by the Vice President for Safety Management.

In California, prescription drug errors are reported into a Drug Furnishing Irregularities database. Analysis and trending of these data identify potential vulnerabilities in the medication system, which upon identification are remedied immediately, and where appropriate, proactive interventions are put into place to ensure that similar errors do not occur in the future.

Adverse drug reactions and medication-related significant events are reviewed by the Pharmacy and Therapeutics Committee. These are evaluated in a similar manner as the Drug Furnishing Irregularities to identify all of the potential contributing causes.

The statewide Adverse Drug Event Prevention Project also uses data from the above sources to identify potential areas for medication safety improvement across the California regions. Additionally, data is collected proactively utilizing the Medication Safety Assessment tools. The group also provides provider education on high-alert medications, best practices and human factors.

Drug-drug interaction alerts are also built into the Pharmacy prescribing/dispensing system that warns the pharmacist about potential conflicts in a patient's medications.

Evidence-based, successful practices in patient safety are housed in the online compendium on the Patient Safety website.

We create and distribute a quarterly, program-wide patient safety newsletter entitled STEPS ("Sharing To Ensure Patient Safety"). We also include patient safety articles in other Kaiser newsletters such as Kaiser Permanente Stat and California Wire (both electronic newsletters) as well as various others.

We have several recognition programs. The David Lawrence Award for Patient Safety is awarded annually to a multidisciplinary project team among any Kaiser Permanente health plan that has shown measurable improvements in patient safety at their facility through their project's implementation. The Vohs Award, another annual program-wide honor, recognizes exceptional regional efforts to address challenging quality-of-care and service issues. Its goal is to highlight multi-disciplinary improvements that are measurable and transferable to other areas within Kaiser Permanente.

Our California medical centers also recognize local champions of patient safety, such as the "Good Catch" program in San Diego, which applauds the efforts of any staff member that identifies a potential vulnerability in the system.