Question

Engineering a Culture of Safety

How do we create an organizational climate in health care that fosters safety, and what are its ingredients? Explain what organizational learning must take place to cause a shift in mindset recognizing the inevitability of errors and proactively seeking latent threats?

Answer 1

Maintaining a safe environment reflects a level of compassion and vigilance for patient welfare that is as important as any other aspect of competent health care. The way to improve safety is to learn about causes of error and use this knowledge to design systems of care to “… make errors less common and less harmful when they do occur”.

Although a healthcare culture of safety has been a practice priority for many years, there has been less attention to incorporating culture of safety content into the education of healthcare professionals. Students need to become knowledgeable about system vulnerabilities and understand how knowledge, skills, and attitudes promoting utilization of safety science will lead to safer care for patients and families. Learning about both patient safety and system vulnerabilities needs to begin in pre-licensure programs and become an integral part of learning in all phases of nursing education and practice.

The goal of a culture of safety is to lessen harm to patients and providers through both system effectiveness and individual performance. Common obstacles to a safe system include complex and risk-prone systems that produce unintended consequences; lack of comprehensive verbal, written, and electronic communication systems; tolerance of stylistic practices and lack of standardization; fear of punishment which inhibits reporting; and lack of ownership for patient safety. Nurses need to be knowledgeable about system vulnerabilities and understand how knowledge, skills, and attitudes promoting the utilization of safety science will lead to higher quality care for patients and families.

It is important to recognize that errors can take place across the healthcare system. Latent failures, sometimes called the ‘blunt’ end, arise from decisions that affect organizational policies, procedures, and allocation of resources. One example would be the purchasing department’s ordering a new type of intravenous pump without input from front-line clinicians. Active failures occur at the interface of contact with the patient, for example during medication administration. These errors are sometimes referred to as the ‘sharp’ end. Organizational system failures, or indirect failures, are related to management, organizational culture, protocols/processes, transferring of knowledge, and external factors, for example decisions regarding staffing and scheduling. Technical failures are the indirect failure of facilities or external resources.

The Institute of Medicine (IOM) has worked to move our emphasis from addressing errors to promoting safety through widespread system changes. The message in To Err is Human was to prevent, recognize, and mitigate harm from error, defined as, the “failure of a planned action to be completed as intended ... or the use of a wrong plan to achieve an aim". Developing a culture of safety in learning organizations, understanding the limits of human factors, and appreciating the reasons for comprehensive reporting mechanisms are all essential components in the preparation of nurses to be participants in 21st Century healthcare. Learning about both patient safety as a fundamental quality of patient care and system vulnerabilities needs to begin in pre-licensure programs and be an integral part of learning in all phases of nursing education and practice.

Essential Elements of a Culture of Safety
Key elements of a culture of safety in an organization include the establishment of safety as an organizational priority, teamwork, patient involvement, openness/transparency, and accountability. In addition a safety culture is characterized by shared core values and goals, non-punitive responses to adverse events and errors, and promotion of safety through education and training. A safety culture requires strong, committed leadership, along with the engagement and empowerment of all employees.

In a culture of safety, a balance is achieved between not blaming individuals for errors and not tolerating egregious behavior. This balance is currently referred to as a ‘just culture’. In a just culture the focus is on effective teamwork to accomplish the goal of safe, high-quality patient care. Traditionally, a culture of blame has been pervasive in healthcare. The focus has often been on trying to determine who has been at fault so that the offender can be disciplined. This approach has led to the hiding, rather than the reporting of errors; it is the antithesis of a culture of safety. In contrast a patient safety culture should be non-punitive and emphasize accountability, excellence, honesty, integrity, and mutual respect. Today, in a culture of safety, when an adverse event occurs, the focus is on what went wrong, not who caused the problem.

A number of tools are available for assessing the healthcare safety culture within an organization. The most widely used is the Culture of Patient Safety Assessment developed by the Agency for Healthcare Research and Quality (AHRQ) describes some of these tools.

1. Agency for Healthcare Research and Quality
2. Premier data tool for managing results of AHRQ culture survey
3. VHA culture survey to assess leadership and organizational culture climate
4. Westat Patient Safety Culture Improvement Tool (PSCIT)

Importance to Know About a Culture of Safety
The Quality and Safety Education for Nurses (QSEN) was developed to identify the competencies pre-licensure and graduate students need for safe practice. QSEN defines safety as minimize(ing) risk of harm to patients and providers through both system effectiveness and individual performance. With funding from the Robert Wood Johnson Foundation a group of experts, with consultation and input from multiple accrediting agencies and professional groups, identified the needed safety competencies and disseminated them via publications. Traditionally education has focused on the care of individual patients/families, with an understanding of the complexity of care delivery systems being notably absent. The QSEN project places considerable emphasis on helping students understand the complexity of care delivery systems.

Faculty are urged to incorporate the QSEN competencies into their teaching about patient and provider safety. One of the QSEN concepts, patient-centered care, ensures the patient is involved in decision making and understands the plan of care thus preventing errors from occurring. Evidence-based practice guides clinicians in using up-to-date science, in addition to considering clinical expertise and patient values, in designing a plan of care. Teamwork and collaboration assist the healthcare team to communicate and work together effectively, using shared decision making to achieve safe, high quality care. Quality improvement provides for trending and analysis of data to be able to benchmark with comparable organizations and identify system vulnerabilities needing correction. Informatics assists clinicians in using information and technology to communicate, access knowledge, and support decision making. The QSEN project has separated quality and safety into two separate competencies to more comprehensively address the science underlying each of the two and to better describe the knowledge, skills, and attitudes necessary for effective practice.

Activities that Promote Safety

The IOM (2001) has identified nine categories that provide opportunities to improve patient safety. Each will be described below. Faculty are encouraged to emphasize the importance of these activities during classroom, laboratory, and clinical teaching.

Incorporating User-Centered Designs
User-centered design approaches visibility, affordance, constraint, and forcing functions. An example of increasing visibility would be a clearly written set of directions on each piece of equipment describing how to return to an earlier step or to change the settings. Affordance indicates how an activity is to be performed, for example marking the correct limb before surgery. A constraint is a device or process that makes it hard to do the wrong thing, while a forcing function makes it impossible to do the wrong thing, such as put the active electrode of the cautery machine into the grounding plate or hook a nasogastric tube to a central line.

Avoiding Reliance on Memory
Standardizing and simplifying processes and procedures decreases the demand on one’s memory, planning, and/or problem-solving processes. The use of protocols and checklists both reduce reliance on memory and serve as reminders for the steps to be followed. Simplifying processes minimizes problem-solving. Establishing the usual dose of a medication as the default in an electronic order entry system and purchasing equipment that is easy to use and maintain are both examples of simplifying processes.

Attending to Work Safety
Work hours, work-loads, staffing ratios, distractions, and interruptions all affect patient safety. In many healthcare settings, realizing that interruptions are a major cause of medication administration errors, nurses have chosen to wear something visually apparent, such as a vest, to indicate they should not be interrupted when they are preparing or administering medications. The use of 'safe zones' and 'sacred spaces' facilitates a safe working environment with minimal distractions for personnel and patients alike.

Avoiding Reliance on Vigilance
Checklists, well-designed alarms, rotating staff, and adequate breaks all decrease the need for remaining vigilant for long periods. The use of well-designed alarms that differentiate a potential emergency, such as a disconnected ventilator needing an immediate response, from a less serious situation, such as an alarm notifying the nurse that an intravenous infusion needs to be adjusted, decrease the need for continuous vigilance. Rotating staff and scheduling staff breaks/meals also decreases the need for remaining vigilant for long periods.

Training for Team Collaboration
The literature is replete with evidence outlining the importance of teamwork and collaboration. Training programs for interprofessional communication and collaboration promote cultures of safety. Skill in effective interprofessional communication and collaboration increase safety, an especially important consideration during transitions in care and hand offs.

Involving Patients in Their Care
Patients and families should be in the center of the care process. It is essential that clinicians include patients and families when making decisions about treatments, offering educational information, and preparing discharge plans. Knowing the plan of care, holding rounds in patient rooms, and having patients/families participate in these rounds all promote patients being at the center and source of control. These practices allow patients to become knowledgeable about their care and correct any misinformation or misunderstandings.

Anticipating the Unexpected
Organizational changes and reorganizations result in new patterns and processes of care. The safe introduction of new processes and technologies requires involvement of front-line users and pilot testing before widespread implementation. Front-line user involvement and pilot testing are essential, for example, when implementing new processes that call for new ways to deliver care, such as changing from a paper record to an electronic healthcare record (EHR). Increasing organizational vigilance with additional staffing and information system resources during the implementation of a new EHR system will promote safer care by preparing for the unexpected breakdowns that may occur when implementing such a large scale change.

Designing for Recovery
Errors will occur despite the best of planning. Designing and planning for recovery will allow reversal of errors, or make it harder for errors associated with irreversible and critical functions to occur. When errors do occur stress levels are often high and problem solving skills may be affected. Simulation training promotes the practice of rescues using models and virtual reality. Practicing what to do in the event of an infant abduction or a blood transfusion error and conducting disaster management drills on a regular basis will promote a smooth recovery.

Improving Access to Accurate, Timely Information
Information for decision making needs to be available at the point of care. This includes easy access to drug formularies, evidence-based-practice protocols, patient records, laboratory reports, and medication administration records. Many organizations now have drug formularies and practice protocols available as applications for smart phones, thus providing for just-in-time information availability.

The human error problem can be viewed in two ways: the person approach and the system approach. Each has its model of error causation and each model gives rise to quite different philosophies of error management. Understanding these differences has important practical implications for coping with the ever present risk of mishaps in clinical practice.

Person approach
The longstanding and widespread tradition of the person approach focuses on the unsafe acts—errors and procedural violations—of people at the sharp end: nurses, physicians, surgeons, anaesthetists, pharmacists, and the like. It views these unsafe acts as arising primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness. Naturally enough, the associated countermeasures are directed mainly at reducing unwanted variability in human behaviour. These methods include poster campaigns that appeal to people's sense of fear, writing another procedure (or adding to existing ones), disciplinary measures, threat of litigation, retraining, naming, blaming, and shaming. Followers of this approach tend to treat errors as moral issues, assuming that bad things happen to bad people—what psychologists have called thejust world hypothesis.

System approach
The basic premise in the system approach is that humans are fallible and errors are to be expected, even in the best organisations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in “upstream” systemic factors. These include recurrent error traps in the workplace and the organisational processes that give rise to them. Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work. A central idea is that of system defences. All hazardous technologies possess barriers and safeguards. When an adverse event occurs, the important issue is not who blundered, but how and why the defences failed.

Evaluating the person approach
The person approach remains the dominant tradition in medicine, as elsewhere. From some perspectives it has much to commend it. Blaming individuals is emotionally more satisfying than targeting institutions. People are viewed as free agents capable of choosing between safe and unsafe modes of behaviour. If something goes wrong, it seems obvious that an individual (or group of individuals) must have been responsible. Seeking as far as possible to uncouple a person's unsafe acts from any institutional responsibility is clearly in the interests of managers. It is also legally more convenient, at least in Britain.

Nevertheless, the person approach has serious shortcomings and is ill suited to the medical domain. Indeed, continued adherence to this approach is likely to thwart the development of safer healthcare institutions.

Error management
Over the past decade researchers into human factors have been increasingly concerned with developing the tools for managing unsafe acts. Error management has two components: limiting the incidence of dangerous errors and—since this will never be wholly effective—creating systems that are better able to tolerate the occurrence of errors and contain their damaging effects. Whereas followers of the person approach direct most of their management resources at trying to make individuals less fallible or wayward, adherents of the system approach strive for a comprehensive management programme aimed at several different targets: the person, the team, the task, the workplace, and the institution as a whole.
High reliability organisations—systems operating in hazardous conditions that have fewer than their fair share of adverse events—offer important models for what constitutes a resilient system. Such a system has intrinsic “safety health”; it is able to withstand its operational dangers and yet still achieve its objectives.

High reliability organisations are the prime examples of the system approach. They anticipate the worst and equip themselves to deal with it at all levels of the organisation. It is hard, even unnatural, for individuals to remain chronically uneasy, so their organisational culture takes on a profound significance. Individuals may forget to be afraid, but the culture of a high reliability organisation provides them with both the reminders and the tools to help them remember. For these organisations, the pursuit of safety is not so much about preventing isolated failures, either human or technical, as about making the system as robust as is practicable in the face of its human and operational hazards. High reliability organisations are not immune to adverse events, but they have learnt the knack of converting these occasional setbacks into enhanced resilience of the system.