I. Purpose

The purpose of the California Patient Safety Action Coalition (CAPSAC) is to enhance patient safety and increase reporting of near misses and medical errors through promoting a fair and just culture across the continuum of healthcare in California. The CAPSAC will strive to protect the public from medical errors by alerting healthcare providers to unsafe systems, and building a structure for accountability for human errors. The CAPSAC will prioritize work based on strategies that are efficient, effective and realistic for healthcare organizations to adopt and utilize. The Coalition represents key stakeholders collaborating to achieve common goals.

The Coalition will seek to educate regulatory agencies, legislators, consumers, healthcare providers, purchasers of healthcare, and the media in principles of a fair and just culture, with the desired outcome being a societal change in the perception and response to medical errors. The Coalition will also serve as a resource to the Department of Public Health, the Center for Healthcare Quality, patient safety institutions, and professional licensing boards; provide opportunities for health care organizations to share best practices; and establish a mechanism for shared learning across organizations to minimize the same errors from occurring again.

A “fair and just culture” in health care organizations is characterized by everyone throughout the organization being aware that medical errors are inevitable and can cause patient harm. As such, every healthcare provider, employee and caregiver feels responsible to report all errors and unintended events even though the events may not cause patient injury. Staff will serve as safety advocates regardless of his/her position within the organization Consumers, healthcare providers, and staff feel supported and safe when voicing concerns because health care organizations and regulatory agencies investigate all reports with a view not to assigning blame, but to identifying and correcting systems and processes of care that contribute to the risk of medical error. As such, all healthcare organizations will promote transparency in appropriately communicating medical facts to the patient and caregiver who have been involved in a medical error. Organizations should develop a framework for disclosure to ensure patients and families receive accurate and timely communication about errors. All caregivers are held accountable for following established procedures for reducing risks to patient safety.

II. Coalition Membership

Active membership in the CAPSAC is defined as healthcare organizations who have embraced the concepts of a fair and just culture by signing the California Statement of Support for a Statewide Culture of Learning, Justice, and Accountability, as well as participation in at least one CAPSAC event within a calendar year. Events include quarterly meetings, CAPSAC regional training events and CAPSAC convening meetings. Representatives from supporting organizations have expressed support of the vision of CAPSAC and concepts of Fair and Just Culture. Attachment A has a list of both active and supporting members.

Coalition members are required to disclose promptly any conflict of interest pertaining to the Coalition’s discussions, recommendations and actions.

III. Coalition Meetings

The Coalition shall meet at least four times annually, and on an ad hoc basis as circumstances dictate. The Coalition may extend invitations to other organizations to participate in the process.

IV. Key Responsibilities

  • Facilitate the adoption of a fair and just culture across health care organizations in California. A Just culture is a learning culture that focuses on proactive management of system design and behavioral choices.
  • Support implementation of effective systems that build on principles of a fair and just culture that translate into transparency and thoughtful disclosure of facts to patients and caregivers who have been impacted by a medical error or near miss..
  • Monitor, evaluate, and discuss patient safety initiatives in progress in other states.
  • Provide opportunities for health care organizations to share best practices; and establish a mechanism for shared learning across organizations to minimize the same errors from occurring again
  • Monitor, evaluate, disseminate, and inform charter members of legislative and regulatory activities related to patient safety
  • Develop strategies to educate and inform consumers and the media in the principles of a fair and just culture
  • Review and assess the adequacy of this Charter every 2 years, and amend as the Coalition deems appropriate.