Teaching the Culture of Safety

Jane Barnsteiner, PhD, RN, FAAN

Disclosures

Online J Issues Nurs. 2011;16(3) 

In This Article

High Reliability Organizations

Organizations that have cultures of safety, foster a learning environment and evidence-based care, promote positive working environments for nurses, and are committed to improving the safety and quality of care are considered to be high reliability organizations (HROs) (Carrol & Rudolph, 2006). HROs are characterized by a safety and quality-centered culture, direct involvement of top and middle leadership, safety and quality efforts that are aligned with the strategic plan, an established infrastructure for safety, and continuous improvement and active engagement of staff across the organization (Bagin et al., 2001; Baker, Day, & Sales, 2006; Shortell et al., 2005). Teaching student to avoid disruptive behavior, enhance their working conditions, avoid workarounds , attend to the human factors in their work setting, coordinate transitions and handoffs, uncover the cause(s) of errors, and disclose errors can help them develop their future work settings into HROs. Each of these activities will be described below.

Workspace designs that promote the flow of patient care and decrease interruptions also decrease the chance of errors and enable organizations to become HROs. Teaching students how to advocate for these working conditions can help them promote cultures of safety. The Joint Commission (TJC, 2008) has identified the pervasive effect of healthcare workers' disruptive behavior on patient safety. Disruptive behaviors include psychological and physical intimidation, as well as overt and covert activities that intimidate or disrupt care. Disruptive behaviors, such as bullying and abuse, have been documented as having a negative effect on quality of care, patient safety, and nurse retention and job satisfaction (Barnsteiner, 2012; Clarke & Donaldson, 2008; Heath, Johnson, & Blake, 2004). Teaching students early in their careers to avoid and prevent these behaviors can contribute significantly to a culture of patient safety and the development of HROs.

Components of the physical environment that negatively impact working conditions can also produce vulnerabilities for both patients and staff. 'No lift' policies and sufficient patient lifting equipment prevent patient and clinician injuries. Limiting work hours and maintaining adequate staffing prevent fatigue leading unsafe care. Workspace designs that promote the flow of patient care and decrease interruptions also decrease the chance of errors and enable organizations to become HROs. Teaching students how to advocate for these working conditions can help them promote cultures of safety.

Workarounds present patient safety hazards. They occur when clinicians encounter problems or impediments in delivering care and invent a quick way (a workaround) to solve the problem. Nurses engage in workarounds because they are busy and need to get the problem solved quickly. An example would be bypassing the barcoding medication administration procedure because the process has too many steps. This frequently used approach to problem solving leaves system problems untreated and can cause errors. Helping students understand the dangers of workarounds and learn how to report and solve problems at the organizational level can help them to become safer clinicians and their work sites to be highly reliable.

Systems need to be designed to protect against human errors; hence the focus needs to be on meeting the needs of clinicians within the healthcare system. 'Human factors' is the science of the interrelationship between humans, the technology they use, and the environment in which they work (Kohn, Corrigan, Donaldson, 2000). Human factors considers our 'human condition' or our inability to perform accurately or focus on multiple things at once (Vicente, 2004). Errors result when one is tired, distracted, or interrupted and in turn deviates from safe operating procedures and standards that can be routine yet necessary (Reason, 2000). Recent studies have reported that nurses were interrupted on the average, almost 12 times per hour, 22% of the time while administering medications, and frequently as they performed safety-critical tasks (Brixey, 2010; Trbovich, Prakash, Steward, Trip, & Savage, 2010). Helping students to understand the complex and demanding clinical environments will help them become aware of the components and relationships that influence the safety of care and the reliability of an organization. Systems need to be designed to protect against human errors; hence the focus needs to be on meeting the needs of clinicians within the healthcare system.

The Joint Commission (TJC) (Joint Commission Center, 2010) has a targeted-solutions initiative to improve the handoff process of transferring and accepting patient care responsibilities from one caregiver to another through effective communication. Handoffs of patient care from one nurse to another are common nursing activities (Dayton & Henriksen, 2007; Riesenberg, Leitsch, & Cunningham, 2010; Sexton et al., 2004). Students need to understand that transitions in care and handoffs create vulnerabilities that require special attention. Central to effective handoffs is effective communication. Standardization in the processes of handoffs and face-to-face communication remains key to maintaining patient safety (Dayton, 2007; Friesen, White, & Byers, 2008; Saint, Kaufman, Thompson, Rogers, & Chenoweth, 2005; Welsh, Flanagan, & Ebright, 2010). Handoffs may be facilitated through the use of standardized, change-of-shift reporting checklists. SBAR (situation, background, assessment, and recommendation) descriptions are now frequently used for both interprofessional communication and nurse-to-nurse communication (Barenfinger et al., 2004; Haig, Sutton, & Whittington, 2006; Hanna, Griswold, Leape, & Bates, 2005). Helping students master safe handoffs will enable them to provide safer care for their patients and develop more highly reliable organizations.

Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA) are methods used to examine factors leading to an adverse event or a close call. Faculty can take advantage of the many available resources describing how to conduct RCAs and FMEAs that are found on the Agency for Healthcare Research and Quality (AHRQ) web site. TJC has suggested these processes be used for all sentinel events and that organizations take appropriate actions to eliminate risks associated with sentinel events that have occurred.

A RCA is completed after an adverse event by outlining the sequence of events that led up to the event and identifying factors that contributed to or caused the event. In identifying such 'root' causes of an adverse event, the five-'whys' approach, which drills down and continues to identify preceding 'causes,' is used to keep discussions about causes focused on the system rather than the people. The idea is to uncover the underlying cause(s) of an error by looking at enabling factors that contributed to the event, such as lack of education; latent conditions, e.g., not checking the patient's ID band; and situational factors, e.g., two patients in the hospital with the same last name, that contributed to or enabled the adverse event (Reiling, Knutzen, & Stoecklein, 2003; Rooney & Vanden Heuvel, 2004).

FMEA is an evaluation technique used to identify and eliminate known and/or potential failures, problems, and errors from a system, design, process, and/or service before they actually occur (Hughes & Blegen, 2008). The goal of a FMEA is to prevent errors by attempting to identify all the ways a process could fail, estimating the probability and consequences of each failure, and taking action to prevent the potential failure from occurring. The simulating of equipment failures has been shown to be a helpful way to hone provider skills, identify equipment vulnerabilities, and evaluate alternative approaches or procedures (Waldrop, Murray, Boulet, & Kraus, 2009).

Nursing faculty are in key positions to help students who may have made even a minor error to recognize both the dangers of becoming a 'second victim' and the need to promote their healing by appreciating the complexity of healthcare situations and by seeking counsel from managers and human resources departments. Accountability to patients and families is a hallmark of a culture of safety. Disclosure of errors to patients is linked to patient safety efforts and is mandated by many state patient-safety requirements. It involves both communicating information about the error and addressing the patient's emotions. HROs in healthcare have in place policies, processes, and training directed toward disclosing healthcare errors and significant near misses to patients and their families. It is important that students understand the disclosure process and develop disclosure communication skills related to the delivery of difficult news.

Healthcare professionals often report feeling worried, guilty, and depressed following serious errors, as well as concern for patient safety and fearful of disciplinary actions (Rassin, Kanti, & Silner, 2005; Rossheim, 2009; Wolf, 2005). They also are aware of their direct responsibility for errors and may blame themselves for serious-outcome errors. Wu (2000) coined the phrase 'second victim' to describe the impact of errors on professionals. Rather than allowing these 'victims' to suffer alone after an adverse event, we need to develop systems to assist clinicians to understand the event, and the often complex circumstances surrounding the event, and to promote their healing, as well as to improve the healthcare system (Denham, 2007; White, Waterman, McCotter, Boyle, & Gallagher, 2008). Nursing faculty are in key positions to help students who may have made even a minor error to recognize both the dangers of becoming a 'second victim' and the need to promote their healing by appreciating the complexity of healthcare situations and by seeking counsel from managers and human resources departments.

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