Coordinates all components of the Patient Safety Program at Exeter Hospital. Leads and participates in all patient safety initiatives and projects.


  • 3 to 5 years of direct experience
  • Master's Degree in directly related field
  • Registered Nurse – NH or Other Compact State
  • Project Management experience
  • Strong analytical skills
  • CPPS within first year

Major Responsibilities:

  1. Culture of Safety: Manages and coordinates the Culture of Safety survey for Exeter Hospital and Core Physicians. Duties to include: utilizing the culture of safety survey results to identify opportunities for improvement; provides interpretation of the culture of survey results to departments; and collaborates with department staff to identify education, training, and process changes.
  2. Leapfrog:  Manages and coordinates all aspects of the Leapfrog Patient Safety survey to work collaboratively with departments on chapter sections to include CPOE testing; develop annual gap analysis, and collaborate with department leaders to identify opportunities for improvement.
  3. Patient Safety Committee: Co-Chairs the Patient Safety Committee with the Medical Director of Quality and Patient Safety. Responsible for input, oversight and monitoring of patient safety metrics and standing agenda to include but not limited to: Culture of Safety, Leapfrog, RCAs, and Risk Events.
  4. RCA and Corrective Action: Manages the RCA process and Corrective Action plans; manages the Adverse Event Response Team Tracker; Activity report for PSC; and coordinates and tracks projects and initiatives related to patient safety, including FMEAs. Work collaboratively with Accreditation team to align with Internal audit Program.
  5. Quality/Risk Events: Reviews daily risk events received in the Midas system triages to various Managers, Risk Management, Subject Experts, Quality and Patient Safety staff; Assists in identifying quality trends. Works collaboratively with Director of Risk Management to develop Harm Report and identify potential risks to patient safety and minimize risk. Partners with the Director of Risk to perform annual risk assessments to identify quality and patient safety opportunities.
  6. Actively participates in the development and implementation model for safety rounding; utilizes safety rounding/internal audit findings proactively to address and mitigate risk points. Implement a standard process for real time post event debriefing.
  7. Education: Conduct Science of Safety training program to staff; develop safety case scenarios to be presented at departmental staff meetings; provide feedback to areas on safety events.
  8. Gathers data from internal and external data services to establish benchmarks and gather information on lessons learned from local, regional, and national patient safety initiatives. Reviews and analyzes PSI 90 report.
  9. Patient safety representative to work collaboratively with patient safety leaders in the organization, as well as the Behavioral Health, Workplace Violence, and other teams that may be formed as a result of trend or serious events.

Location: Exeter Hospital · EH-Quality Assurance-BHUGH
Schedule: full time, Day Shift, 8:00-5:00pm; variable

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