Description

The action plan that addresses the cause or finding and is designed to prevent occurrence of similar events. A system-level action plan focuses on processes, practices, and procedures, rather than individuals, and has the greatest likelihood of preventing future occurrences.

On-Screen Instructions

n/a

Field Type

Text

Guide for Use

Show a clear link between the cause and the action plan.

What counts as a system-level action plan in the Patient Safety Reporting Program (PSRP)?

When asked to report system-level action plans to PSRP, facilities often ask how far-reaching an action plan must be to qualify as system-level. The question may arise for facilities that are not part of a larger healthcare system or for facilities that are a part of a larger healthcare system but are implementing an action plan in only one location. The goal of a system-level action plan is to increase safety in the long term and not allow a similar event to occur. To accomplish this, action plans must move beyond solving the problem in just one instance and include other patients, providers, or practices in similar circumstances. Only then will safety be improved in the long term.

Oftentimes, creating a system-level action plan can be complicated by how a facility is staffed. When facilities use staff that they do not employ, implementing a system-level action plan facility-wide can be more difficult. For example, ensuring that float RNs, independent providers, locums, or traveling nurses are aware of and able to implement a system-level action plan can take significant effort. When creating an action plan, make sure that your plan applies to all relevant staff or providers working in your facility and that they are equipped to follow through.

When assessing if your action plan is truly system-level, first determine if your plan will positively impact other patients or providers in a similar situation. If the answer is yes, you’re on the right track! For assistance developing system-level action plans, please contact your Oregon Patient Safety Commission (OPSC) Patient Safety System Analyst.

What is the difference between a treatment plan and an action plan?

PSRP gathers information on adverse events that occur in Oregon healthcare facilities to create a statewide database for shared learning. Facilities that report adverse events to the program improve patient safety by investigating what went wrong and sharing strategies that will prevent similar harm from occurring in the future. 

When responding to adverse events, it is essential to develop plans that result in system-wide patient safety impact, as opposed to simply addressing each individual situation. A treatment plan focuses on the needs of a single patient, and often does not result in system-wide patient safety impact. A system-level action plan focuses on processes, practices, and procedures, rather than individuals, and has a greater likelihood of preventing future occurrences.

History