Blameless or blameworthy errors: Does your organization make a distinction?

Preventable patient harm events result in millions of dollars in additional care as well as the unnecessary grief and suffering of patients and their families. A strong safety culture allows for the identification and elimination of risk and harm, while the lack of a safety culture results in the concealment of errors.

Human fallibility

Despite widespread attention to the concept of a safety culture, the Agency for Healthcare Research and Quality’s (AHRQ) 2011 Hospital Survey on Patient Safety Culture revealed a demonstrable need for continued improvements in patient safety. More than 472,000 hospital staff members at approximately 1,000 hospitals responded to the survey and reported the following:

  •  A total of 44 percent felt that mistakes would not be held against them.
  • A total of 54 percent had not reported any events in the previous 12 months.
  • A total of 75 percent rated their work area either as excellent or very good in terms of patient safety.1

These figures suggest that survey respondents give their work areas high marks for patient safety. However, more than half of those surveyed are concerned that errors would be held against them, with more than half of respondents not reporting any preventable harm incidents over the course of a year. This high ranking for patient safety work areas combined with low rates for reporting of these incidents would seem to indicate that adverse and sentinel events are infrequent occurrences. However, the opposite may be true, as supported by recent literature suggesting that adverse events occur in one-third of hospital admissions.2

Creating a safety culture

Clearly the safety culture within health care organizations needs reinforcement and strengthening. A strong safety culture fully supports high reliability and is focused on three action items: trust, report, and improve. A safety culture is centered on a strong management infrastructure, particularly in organizations that take a holistic, whole-of-community, whole-life approach to the delivery of patient care. A successful safety culture also requires a constant assessment of the safety significance of events and issues so that the appropriate level of attention can be given to problems. For a safety culture to progress or be sustained over time, the elements of a culture must be measured through a survey that evaluates and analyzes current protocols and results in specific, focused interventions based on areas where the organization is coming up short.

Blame-free versus accountability

It also is important to note that the aim of a safety culture is not a blame-free culture. Rather, a safety culture balances learning with accountability, assesses errors and patterns in a uniform manner, and eliminates unprofessional or intimidating behaviors. Specific characteristics of a safety culture include the following:

  • Self-governed codes of behavior
  • Personal accountability recognized by all staff
  • Equitable and transparent disciplinary procedures
  • Routine reporting of close calls and unsafe conditions
  • Proactive assessment of system weaknesses and processes for addressing any deficiencies

A crucial component of safety culture is an equitable and transparent process for recognizing and separating small, blameless errors that fallible humans make daily, from unsafe or reckless acts that are blameworthy.3 The trust, report, and improve cycle allows for proactive and reactive risk reduction because staff report errors, close calls, and unsafe situations. Proactive risk reduction solves problems before patients are harmed and is similar to failure mode and effect analyses used to evaluate processes to identify risks. Reactive risk reduction attempts to prevent problems from harming patients in the future and is similar to root cause analyses used in response to a sentinel event. A nonpunitive reporting environment is essential in moving from reactive risk reduction to proactive risk reduction, in which all members of the organization are focused on patient safety.

System, rather than human, errors

In 1997, James Reason, PhD, a leader in the area of patient safety, suggested three key ingredients for creating a safety culture: commitment, competence, and cognizance—the three Cs.4 When a patient safety event is the result of an honest error, the entire system that supports the performance in question should be evaluated. Events triggered by human error are often symptomatic of a system failure. Instead of asking how the individual failed the organization at the sharp end, the more appropriate question should be, “How did the organization fail the individual?” What flaws or oversights in work processes, policies, or procedures at the blunt end of the spectrum contributed, promoted, or allowed the incident to occur?

Because most events originate in the system of controls, processes, and values that are established by the management team, management’s first reaction to events should be to look within the organization. Second, if an incident is observed or reported in an organization and it has caused or has the potential to cause patient harm, it is important that organization leaders use a process improvement methodology in all departments, programs, and services to monitor problem-prone or high-risk areas, identify root causes of these adverse events, and disseminate lessons learned to staff members.

Physicians and safety culture

Physicians and other health care leaders must develop and encourage the use of systems for blame-free, internal reporting of a system or process failure. The Joint Commission provides leaders of health care institutions with a framework to strengthen an organization’s culture, reflecting the beliefs, attitudes, and priorities of staff and employees. This blueprint is found in the “Leadership” chapter of The Joint Commission’s accreditation manuals. The five key systems—using data, planning, communicating, changing performance, and staffing—serve as pillars that leaders may use to support the individual care, treatment, and services they provide.

The Joint Commission also recommends the use of Robust Process Improvement (RPI) to improve safety and quality. RPI is centered on leadership, safety culture, Lean Six Sigma, and change management techniques. A Joint Commission Center for Transforming Healthcare project is currently under way in which seven hospitals are using RPI to optimize behaviors and practices that result in an improved safety culture, reinforcing and supporting the prevention of patient harm. For more information about the project, visit http://www.centerfortransforminghealthcare.org/projects/detail.aspx?Project=6.

 


References

  1. Agency for Healthcare Research and Quality. Executive summary. 2011 user comparative database report. Available at: http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/2011/hosp11summ.html. Accessed January 17, 2013.
  2. Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A, James BC. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff. 2011;30(4):581-589.
  3. Chassin M, Loeb J. High-reliability health care: Getting there from here. Milbank Q. 2013;91(3):459-490.
  4. Reason J. Managing the Risks of Organizational Accidents. Aldershot, England: Ashgate; 1997.

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