Patient Safety Programs and Just Culture
Reducing and eliminating potential harm to patients
Prior to the 1999 publication of the Institute of Medicine's landmark report, "To Err is Human," healthcare organizations engaged in investigations of events that caused harm to patients. Few of these investigations, however, engaged in a systems-based approach to problem solving. The focus was on individuals and mistakes, rather than on the cluster of events that had combined in an unfortunate sequence to cause an incident to occur. Based on a "name and blame" culture, the emphasis of such investigations was not on prevention, but on punishment.
Safer Healthcare teaches teams about the shifting of organizational goals and local culture from eliminating errors to reducing or eliminating harm to patients. This is accomplished through the analysis and improvement of medical care systems, rather than focusing on individual acts. It begins with an in-depth look at the organization's people, process and technology.
At the heart of every patient safety training program is a simple objective: the reduction and prevention of inadvertent harm to patients as a result of their care.
Reducing or eliminating harm to patients is the key to the delivery of safe and highly reliable patient safety. Efforts that focus exclusively on eliminating errors will fail. Because of the role of individuals in care, individual errors will always remain; however, they can be "trapped" or recognized before they reach the patient. The goal is to design systems that are "fault tolerant," so that when an individual error occurs, it does not result in harm to a patient.
Creating a just culture promotes both professional accountability and reporting of medical errors. Analyzing medical errors is a critical component of improving patient safety and patient safety education within healthcare facilities. Analytical methods will not work if your team is bound by a "code of silence" or if individuals are fearful of retribution. A just culture fosters a professional environment that includes reporting systems and processes for improving patient safety and patient safety training through organized analysis and programs.
Safer Healthcare's patient safety programs are designed on an organizational-wide systems approach to problem solving - focused on prevention, not punishment. We use methods and apply ideas from high reliability organizations, such as aviation, nuclear power, the military and other at-risk industries to target and eliminate system vulnerabilities.
Organizations and local healthcare managers should not target people in a "name and blame" culture that existed in the past. Successful leaders will look for ways to break that link in the chain of events that can create a recurring problem: those underlying systems-based problems that have remained ignored or unaddressed. One of the most important ways to do this is to learn from close calls, sometimes called "near misses," which occur at a much higher frequency than actual adverse events.
Addressing problems in this way not only results in safer systems, but it also focuses everyone's efforts on continually identifying potential problems and fixing them.
The overriding goal of a creating a "just culture" is to create a system through patient safety education and just culture programs that delineate what type of activities may result in blame and which don't. Only those events that are judged to be an intentionally unsafe act can result in the assignment of blame and punitive action. Intentional unsafe acts, as they pertain to patients, are any events that result from a criminal act, a purposefully unsafe act, or an act related to alcohol or substance abuse or patient abuse. The integration of these approaches across the organization creates a level of trust and a focus of efforts that helps sustain a culture of safety.
Healthcare organizations should strive to create a culture of patient safety that encompasses the following elements:
- Patient safety should be valued as a top priority, even at the expense of productivity
- A just culture is a healthcare environment where actions are analyzed to ensure that individual accountability is established and appropriate actions are taken
- A commitment to safety must be articulated at all levels of the organization, from the executive suite to the direct interaction with patients at the floor level
Safer Healthcare works closely with healthcare organizations and healthcare leadership teams to align program goals with organizational initiatives through a full range of services, including executive coaching, strategic consulting and leadership development programs and workshops.
Learn More about Safer Healthcare's Just Culture and Patient Safety Programs
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