INSTITUTIONAL STRATEGIES FOR ADDRESSING ERRORS
Essential strategies healthcare facilities must consider in their efforts to reduce medical errors include:
- Changes in organizational culture
- Involvement of leadership
- Education of providers
- Development of patient safety committees
- Adoption of safe protocols and procedures
- Use of technology
(AHRQ, 2019f)
Creating a Culture of Safety
A culture of safety encompasses the following key features:
- Acknowledging the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations
- Fostering a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
- Encouraging collaboration across ranks and disciplines to seek solutions to patient safety problems
- Committing organizational resources to address safety concerns
(AHRQ, 2019f)
JUST CULTURE MODEL
A just culture is defined as organizational accountability for the systems they have designed and employee accountability for the choices they make. In such a setting, trust is critical to shared accountability. Trust in leaders is defined as the perception that healthcare employees will receive fair treatment from leaders following an adverse event, regardless of their position in the hospital or the event’s severity. In such a highly reliable organization, employees routinely identify and report unsafe conditions and errors because they trust leaders want to know what is not working and will implement visible and meaningful improvements with this information.
All types of errors hold equal importance in a just culture, not just those with poor outcomes. To build trust, error identification and reporting are encouraged to provide opportunities for staff education and system redesign.
Two important features of a just culture include 1) a nonblaming incident investigation and 2) understanding the behavioral choices that a person makes (Paradiso & Sweeney, 2019).
Leadership
Hospital boards now use strategic initiatives to influence quality and safety, however, data shows that executives and management can further improve safety by having more direct interactions with frontline workers. Visits by management (walkarounds) to clinical areas to engage in open and frank discussions with the staff about safety concerns have been shown to have a positive impact on safety culture. To be credible among frontline staff during these walkarounds, however, it is important that issues raised by the staff be addressed promptly and that leaders follow up sufficiently after an error has been reported.
Leadership can also directly address safety concerns by recognizing and managing disruptive and unprofessional behavior by clinicians. As boards have oversight over the medical staff, they have the ability to ensure unprofessional or incompetent clinicians do not put patients at risk (AHRQ, 2019g).