Teaching the Culture of Safety

Jane Barnsteiner, PhD, RN, FAAN

Disclosures

Online J Issues Nurs. 2011;16(3) 

In This Article

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

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… 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

The use of protocols and checklists both reduce reliance on memory and serve as reminders for the steps to be followed. 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

Designing and planning for recovery will allow reversal of errors, or make it harder for errors associated with irreversible and critical functions to occur. 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.

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