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For other articles and previous issues click here. October 25, 2004 Creating
a Culture of Safety The stories are legion. A patient enters the hospital to have his diseased left kidney removed and emerges from surgery with the failing kidney remaining and the healthy kidney removed. As the result of a confusing drug abbreviation, a patient is given the wrong medication and suffers an adverse reaction. Another patient is given a drug meant for the patient in the next bed. A less fortunate patient is given the wrong dose of the right medicine—a fatal error. These near misses, close calls, and outright disasters occur on a shockingly regular basis despite alarms resounding throughout the healthcare system and a continual drumbeat calling for stringent safety measures. Since November 1999, when the Institute of Medicine issued its high-impact report “To Err Is Human: Building a Safer Health System,” mandates to eradicate safety lapses have emerged at the top of the list of healthcare imperatives. As tragedies associated with a variety of medical errors—from surgical site mistakes to medication errors and equipment malfunctions—increasingly become fodder for the media, healthcare organizations are scrambling to develop programs that will safeguard their patients and restore confidence. To help them, a variety of businesses, accreditation agencies, and nonprofit organizations have devised standards and compiled best practices. For example, each year JCAHO issues National Patient Safety Goals that must be achieved by facilities seeking to gain or sustain accreditation. The government, professional associations, and public organizations offer incentives while accrediting agencies bestow praise for the widespread adoption of information technology such as electronic medical records and computerized order entry systems. Many hospitals are also turning to technology to address other point-of-care errors. Bar coding, for example, helps caregivers identify patients and match them to appropriate drugs, specimens, or procedures. Alarm systems are being redesigned to ensure that they can be heard by distant caregivers, and hospital equipment is being redesigned to prevent dreadful mishaps. Although few would criticize standards, goals, and technologies that might be effective in the war against medical errors, a number of voices are calling for measures that focus less on the individual errors and solutions and more on the climate in which errors can occur and the development of an environment generally more attuned to safety. What’s needed, they suggest, are a systems approach that looks at the overall picture, a more inclusive effort that targets not only direct caregivers but all healthcare employees, and a nonpunitive system of reporting and communicating problems. A Systems Approach It’s not that Merry doesn’t support safety initiatives such as JCAHO’s National Patient Safety Goals. He and other experts applaud such standards and uphold the widespread use of technology, yet argue that a broader approach is needed to create an evolution. Perhaps more important than the adoption of specific safety strategies designed to prevent specific errors is the adoption of a philosophy that supports systemwide communication, analysis, and change. JCAHO, Merry notes, responded positively to the Institute of Medicine report by focusing on safety and becoming proactive—an effort he commends. However, he notes, “the data keep piling up that we’re not fixing the problem out there. These accrediting bodies are targeting the right issues—for example, wrong-site surgery and medication errors. They’re gathering a lot of data on what is effective and what is not.” Nevertheless, he insists, compliance-related activities are absorbing too much energy from talented and dedicated professionals who could be doing more. The compliance industry, he suggests, “will never have a powerful enough lens to really detect the problems.” Merry wonders whether these individuals are really creating and sustaining safer environments or merely creating programs that look good for surveyors. “We’re going to find out over the next five to 10 years because we’ll see a differentiation of those facilities that really do learn how to create safer environments from those that are merely stuck in the compliance game,” he says. Ruth Ragusa, RN, vice president of performance improvement at South Nassau Communities Hospital, Oceanside, N.Y., suggests that JCAHO’s National Patient Safety Goals are a logical way of allowing facilities to learn from the experiences of other organizations that have had tragic events. The most important aspect of the goals, however, is that they highlight the issue and raise staff awareness. According to Annette Watson, RN, CCM, MBA, a senior vice president of the American Accreditation HealthCare Commission (URAC), an independent nonprofit organization that promotes healthcare quality through accreditation and other programs, “There’s been a lot of really good work done over the last few years by many people, including accrediting agencies, but what is needed—and what the Institute of Medicine suggested in its report—is a more broad approach.” Many current initiatives focus on the interaction between caregiver and patient, but the problem is much bigger, Watson suggests. “It takes transformation across the healthcare industry to really ensure safety,” she says. URAC recently released a draft of voluntary Informational Patient Safety Standards (www.urac.org) designed to be used to help implement patient safety programs. Although created to be used in settings other than hospitals—specifically in the medical management arena—these standards can be adopted by all types of healthcare organizations, including hospitals, to help broaden the commitment to creating a safe environment. The foundation of all safety efforts, experts suggest, must be a systems approach. Watson points to theories emerging at the turn of the century that defined a system as a group of interdependencies, processes, and services that have a common aim. To tackle safety issues in a hospital—a clear example of a system—each element in the system must be considered and analyzed. “Technology is a tool to creating a systems approach, and it certainly helps everyone share information,” she says, “but it’s not the end-all and be-all.” According to David Seifert, principal of Patient Safety Advantage—a new approach from the Partnership For Patient Safety (www.p4ps.org) for embedding best practices and creating sustainable cultures of safety and reliability—organizations need to look across their systems at how they implement processes. Seifert, formerly CEO at the 800-bed St. Anthony’s Medical Center in St. Louis, indicates that a systems approach is circular rather than linear—that is, it doesn’t have an end point. “You define the problem, you grasp the best alternatives, and put them in place,” but you don’t stop there, he observes. “You then measure the results and get feedback so you know that you’re accomplishing what you set out to achieve. It involves having a matrix that traces the performance of solutions so that you can make changes and ensure that they’re working smoothly.” An Atmosphere of Inclusion Watson, Seifert, and Merry agree that cultural transformation can take place only if everyone participates. A culture of safety is created, Watson says, when everyone works together across the continuum of healthcare, whether it’s those who provide direct patient care or those who support that care through health plans, health networks, case management, utilization review, or disease management. “It’s not just the role of one person, one provider, or one facility,” she notes. Dropping the Blame Game Yet in organizations that don’t develop nonpunitive systems, many on the front lines are afraid to speak out. Merry says organizations with strong leadership want to know everything that’s going wrong. “They want to know about all the glitches, all the near misses, all the mistakes that are being made—not to root out people to punish, but to gather a database with which they can really begin to analyze where their vulnerabilities are and where their patients are at risk, and to figure out how they can use that information to begin to redesign safer systems.” The thrust of URAC’s voluntary standards, explains Watson, is to foster organizationwide inclusion in safety efforts and find ways to do so in a nonpunitive way. “There’s a tendency to look for fault or blame,” she says. “Historically, it’s not been safe for healthcare personnel to report errors or talk about what could be done better for fear of repercussions.” She’s quick to point to the irony contained in “To Err is Human.” “We’re all human, but mistakes can’t happen in a medical setting because of the nature of the resulting negative outcomes. Unfortunately, there isn’t room for error.” Creating a culture of safety is about moving away from the fear of discussing human fragility and the occurrence of errors. At South Nassau Communities Hospital, patient safety is everyone’s job. According to Ragusa, the staff is a gold mine of information about fragile spots with respect to safety. “Each year we survey our staff anonymously and ask them to identify any risk points that they see and discuss any negative experiences they might have had,” she says. Because being able to speak freely is key to keeping information flowing, the hospital also has an anonymous hotline through which anyone on staff can report concerns. “What we really try to do is look for near misses,” says Ragusa. Close calls, she explains, are opportunities to learn. By taking them apart, seeing what led to them, analyzing them, and looking at what can be done to change the systems in which they occur, hospital staff can minimize future risk. Although it’s not the most desirable approach, Watson says there is a track record for anonymity. Currently, she acknowledges, it’s just not safe for people to openly discuss errors. Anonymity makes people feel they can safely talk about things for which they might otherwise be blamed or that may have repercussions for their colleagues. “If anonymity helps us get there, that’s great,” she says. “But the ideal in the long term would be that open and identifiable reporting of errors and problems could occur and people wouldn’t fear punitive reactions.” “Anonymity isn’t a bad idea. Everybody has to start where they can start,” agrees Seifert. A better approach, however, is to begin with an understanding that there needn’t be fear of retaliation or repercussion. “In a culture of safety, you develop an openness and an appreciation for learning from mistakes,” he says. “You don’t sweep mistakes under the carpet, blame them on someone else, or deny that there’s a problem.” That doesn’t mean you’re not holding people accountable, Seifert is quick to point out. “Knowing that you need to be accountable makes you more proactive. But we’re not going to learn from our mistakes in a culture where there is only finger-pointing and blaming and everyone is scared to talk.” Almost any hospital can get to the point of change from a blame culture to a blame-free culture, he says, if the senior leadership of both the administrative and medical staffs are willing to communicate a commitment to a nonpunitive culture and act accordingly. “We all have a responsibility to do whatever we can to improve safety for patients,” says Ragusa. “You don’t do it because it’s required but because it makes good sense.” Although none of the experts calling for a culture of safety reject specific goals and standards—each, in fact, applauds any effective strategy—they argue compellingly for an effort to see the forest for the trees. “Certainly, specific actions healthcare organizations can take in their facility-whether it’s bar coding or computerized order entry-will help address the tip of the iceberg,” says Watson. “But as we drill down, what we’re really talking about is creating a safety net.” Errors, she says, are the end point of systems’ failures, and through the creation of a culture of safety—a safety net—their incidence will reduce over time. Hospitals have had no choice but to focus singlemindedly on specific errors and their prevention. Now, as healthcare moves beyond crisis, it must look at the bigger picture. — Kate Jackson is a staff writer for Radiology Today. |
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