It’s no secret — as humans, we make errors. The problem is that in healthcare, these errors can cause patient harm, including death. In fact, the Journal of Patient Safety asserts that medical errors in the hospital are the third leading cause of death in the United States. In other words, it is not a matter of if there will be an error, but when.
One of the most important ways you can improve patient safety and reduce errors is to create a culture of safety, often referred to as “Just Culture." A culture of safety in one where everyone is treated with respect and the focus is on teamwork and communication. The ultimate goal is that staff will feel comfortable verbalizing issues related to patient safety.
Gone are the days of punitive action for a staff member who makes an error. Most medical errors are related, at least in part, to systems problems. So punishing the individual does not solve the systems problem. Today’s patient safety movement focuses on having employees feel comfortable enough to report an error so that everyone can discuss it and work together to create a solution that will prevent the error from reoccurring. Although hierarchies can be important, when they prevent staff from feeling comfortable sharing matters related to patient safety, they are dangerous to our patients. Staff should not feel intimidated or afraid to share patient safety information.
Are patients in your office and/or hospital at risk because of any of the following?
- Staff are afraid to ask questions when something does not seem right
- Staff feel like their mistakes are held against them
- The quantity of the work done is more important than the quality of care
- Staff are using workarounds to avoid important patient safety steps
- Recurrent patient safety problems are not addressed
Or, does your office and/or hospital actively promote patient safety by:
- Treating everyone with respect
- Ensuring staff are comfortable questioning those with more authority
- Encouraging staff to report mistakes they make or observe without fear of judgment
- Listening to staff ideas about patient safety and how to improve office processes
- Conducting group discussions on ways to prevent errors from reoccurring
A culture of safety encourages staff, and allows them the time to double check items they are unsure about. It allows for hierarchies but does not make them so steep that staff is reluctant to share errors, potential errors, or patient safety concerns for fear of judgment or discipline. It encourages staff to voice their concerns and to work together to formulate a system or plan that improves the systems in order to promote patient safety. In other words, a culture of safety recognizes that all humans make mistakes. And the best way to address this is by implementing a process of teamwork and improved communication that focuses on improving patient safety.
The Agency for Healthcare Research and Quality (AHRQ) has a Medical Office Survey on Patient Safety Culture available here. This survey is designed to determine whether your office has a culture of safety. In addition to the survey for medical offices, the AHRQ also has culture surveys for hospitals, ambulatory surgery centers, and nursing home facilities.
Kimberly Danebrock is CAPAssurance Director of Risk Management. Questions or comments related to this article should be directed to kdanebrock@CAPphysicians.com. The information in this publication should not be considered legal or medical advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.