• Section 7. Building a Safety Culture

    Video Lecture #3 – Building a Safety Culture

    Safety Culture

    The Agency for Healthcare Research and Quality, Department of Health and Human Resources, notes that the concept of safety culture originated outside healthcare, in studies of high reliability organizations, organizations that consistently minimize adverse events despite carrying out intrinsically complex and hazardous work. High reliability organizations maintain a commitment to safety at all levels, from frontline providers to managers and executives. This commitment establishes a "culture of safety" that encompasses these key features:23

    • Acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations
    • A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
    • Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
    • Organizational commitment of resources to address safety concerns

    Improving the culture of safety within healthcare is an essential component of preventing or reducing errors and improving overall healthcare quality. Studies have documented considerable variation in perceptions of safety culture across organizations and job descriptions. In prior surveys, nurses have consistently complained of the lack of a blame-free environment, and providers at all levels have noted problems with organizational commitment to establishing a culture of safety. The underlying reasons for the underdeveloped healthcare safety culture are complex, with poor teamwork and communication, a "culture of low expectations," and authority gradients all playing a role.

    Measuring and Achieving a Safety Culture

    Staff CommunicationSafety culture has been defined and can be measured, and poorly perceived safety culture has been linked to increased error rates. However, achieving sustained improvements in safety culture can be difficult. Specific measures, such as teamwork training, executive walk rounds, and establishing unit-based safety teams, have been associated with improvements in safety culture measurements but have not yet been convincingly linked to lower error rates. Other methods, such as rapid response teams and structured communication methods such as SBAR (Situation Background Assessment Recommendation), are being widely implemented to help address cultural issues such as rigid hierarchies and communication problems, but their effect on overall safety culture and error rates remains unproven.

    The culture of individual blame still dominant and traditional in healthcare undoubtedly impairs the advancement of a safety culture. One issue is that, while "no blame" is the appropriate stance for many errors, certain errors do seem blameworthy and demand accountability. In an effort to reconcile the twin needs for no-blame and appropriate accountability, the concept of "just culture" is being introduced.

    A just culture focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior. It distinguishes between human error (e.g., slips), at-risk behavior (e.g., taking shortcuts), and reckless behavior (e.g., ignoring required safety steps), in contrast to an overarching "no-blame" approach still favored by some. In a just culture, the response to an error or near miss is predicated on the type of behavior associated with the error, and not the severity of the event. For example, reckless behavior such as refusing to perform a "time-out" prior to surgery would merit punitive action, even if patients were not harmed.

    Safety culture is fundamentally a local problem, in that wide variations in the perception of safety culture can exist within a single organization. The perception of safety culture might be high in one unit within a hospital and low in another unit, or high among management and low among frontline workers.

    Research also shows that individual provider burnout negatively affects safety culture perception. These variations likely contribute to the mixed record of interventions intended to improve safety climate and reduce errors. Therefore, organizational leadership must be deeply involved with and attentive to the issues frontline workers face, and they must understand the established norms and "hidden culture" that often guide behavior. Many determinants of safety culture are dependent on inter-professional relationships and other local circumstances, and thus changing safety culture occurs at a microsystem level. As a result, safety culture improvement often needs to emphasize incremental changes to providers' everyday behaviors.

    Reducing Staff Communication Errors

    Brigham and Women’s Faulkner Hospital has implemented steps to reduce the potential for staff communication errors.24

    No one person can work all the time so it can mean critical information regarding a patients’ care may not get communicated fully from one shift to the next.

    From the kitchen to the bedside to the Pharmacy, every change of shift or hand off between staff within a shift has the potential to impact patient care.

    In the Food and Nutrition Department, a dietitian might have nutrition or meal information regarding a patient that is discussed verbally and doesn’t get documented in the medical record. When the next dietitian works with the patient, that key information is lost. “We realized that while the daily Partners eCare report lists necessary clinical information, some pertinent information related to food and nutrition may not be included in the medical record. The dietitians will now make notes on that report to communicate different nuances about the patient for the next dietitian that will be covering that patient,” says Director of Food and Nutrition Susan Langill, RD, LDN. The team also has a whiteboard in the diet office where they can leave notes for one another, for the call center and for the tray passers.

    In the ICU, a similar system is being used. “We implemented a change of shift whiteboard report during which both oncoming and off-going shifts congregate at the whiteboard and give a brief update on every patient in the ICU,” says ICU Nurse Director Pat Marinelli, MSN, RN, NP.  The team even has icons that they can stick on the whiteboard to improve cues for the staff. For example, they use a small car to mean the patient is traveling off the floor.

    Similarly, the Pharmacy staff expressed concern over hand offs from the night shift to the day shift. Director of Pharmacy Services Joseph O’Day, MBA, RPh, decided to implement more formal communication between the shifts. Staff now document their hand offs by cosigning a log book. The book creates accountability and allows for tracking implementation of the new process.

    Five Steps to Safer Patient Healthcare

    The Patient Fact Sheet was developed by the U.S. Department of Health and Human Services in partnership with the American Hospital Association and the American Medical Association. It recommends that patients be encouraged to take a more active role in their own medical care. The Patient Fact Sheet’s goal is to help Prevent Medical Errors. Here are the five recommended steps that patients are advised to do:25

    1. Ask questions if they have doubts or concerns.

    Ask questions and make sure they understand the answers. Choose a doctor they feel comfortable talking to. Take a relative or friend with them to help ask questions and understand the answers.

    2. Keep and bring a list of ALL the medicines they take.

    Give the doctor and pharmacist a list of all the medicines that they take, including non-prescription medicines. Tell them about any drug allergies they have. Ask about side effects and what to avoid while taking the medicine. Read the label when they get their medicine, including all warnings. Make sure your medicine is what the doctor ordered and know how to use it. Ask the pharmacist about their medicine if it looks different than they expected.

    3. Get the results of any test or procedure.

    Ask when and how they will get the results of tests or procedures. Don't assume the results are fine if they do not get them when expected, be it in person, by phone, or by mail. Call their doctor and ask for the results. Ask what the results mean for their care.

    4. Talk to the doctor about which hospital is best for their health needs.

    Ask the doctor about which hospital has the best care and results for their condition if they have more than one hospital to choose from. Be sure they understand the instructions you get about follow up care when they leave the hospital.

    5. Make sure they understand what will happen if they need surgery.

    Make sure the patient, their doctor, and surgeon all agree on exactly what will be done during the operation. Ask the doctor, "Who will manage my care when I am in the hospital?" Ask the surgeon:

     Exactly what will you be doing?

    About how long will it take?

    What will happen after the surgery?

    How can I expect to feel during recovery?

    Section 6. National Patient Safety GoalsSection 8. Reducing Medication Errors