Medical Staff House Staff Orientation Manual - Montefiore Medical ...

The Patient Safety Officer and the Medical Director, Quality Management, co-chair the
institutional Patient Safety Committee. Membership includes representatives of areas within the
delivery system who have oversight for activities that are fundamentally relevant to improving
patient safety. Broad based representation allows for coordination and communication of
activities across the delivery system.
The 3 primary functions of the Patient Safety Officer and Committee can be summarized as:
• Compliance with patient safety related regulations, including JCAHO patient safety
standards and goals
• Coordination and integration of patient safety activities across the institution
• Communication of patient safety related information to leadership, associates, patients
and families
The scope of activities of the Patient Safety Program enabled by the Patient Safety Officer and
Patient Safety Committee, in conjunction with owners of various patient safety related content
areas, include:
• Review and facilitation of institutional activities enhancing patient safety, including
activities relating to:
• Proactive risk reduction activities
• Errors
• Adverse and critical events
• “Near miss” events – variations in healthcare process not affecting outcomes, but
where recurrences carry significant chances of adverse outcomes
• “No-harm” events – unintended acts of omission or commission that do not result in
adverse outcomes
• Facilitating:
• Communication of patient safety related information throughout the organization
• Education of leadership, associates, patients and families with respect to patient
safety
• Annual redesign of at least one high risk process for proactive risk reduction (failure
modes and effects analysis)
• Assessment and refinement of MMC policies and procedures to be in compliance with
regulations, including JCAHO patient safety standards and goals
• Review of information from patients, families and associates to improve patient safety
• An annual report on institutional patient safety activities
PHARMACY SERVICES
MOSES 718-920-4529
The Moses Pharmacy Department is composed of a centralized pharmacy and six satellites or
decentralized pharmacies. The central pharmacy facility and pediatric satellite are open 24 hours
a day, 7 days a week. The central pharmacy is located in the Storage Building, Orange Zone and
can be reached at phone number 920-4103. The pediatric pharmacy is located in the Children’s
Hospital at Montefiore on the sixth floor and can be reached at phone number 741-2626. The
TPN production area can be reached
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