Proposed Interventions

The following are some proposed interventions for the identified problem:

1. Educate all clinical staff about "Just Culture" and importance of reporting errors

2. Fireside chat with CNO/Chief APP, monthly or biweekly, in order to allow for bidirectional conversations

3. Anonymous 360 review for managers, in order to decrease fear and tackle leadership performance

4. Major change: Remove safety event submissions from departmental heads and allow for independent teams to review all safety events and reports. This would require a restructuring of the patient safety section of the Quality and Safety department. Based on literature and practice, this is the only intervention that works effectively.

5. Minor change: "Good Catch" award provided monthly to praise employees for near misses that were caught.

6. Develop Quality and Safety council for APPs

7. Establish a dedicated Quality and Safety leader for APPs