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

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
• A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
• Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
• Organizational commitment of resources to address safety concerns

Specific measures, such as teamwork training, executive walk-arounds, and establishing unit-based safety teams, have been associated with improvements in safety culture measurements and have been linked to lower error rates. Other methods, such as rapid response teams and structured communication methods such as SBAR, are being implemented widely to help address cultural issues such as rigid hierarchies and communication problems, but their effect on overall safety culture and error rates remain unproven.

The culture of individual blame still dominates and is traditional in healthcare, which impairs the advancement of a safety culture. One issue of concern is that, while “no blame” is the appropriate stance for many errors, certain errors do seem blameworthy and demand accountability. In an effort to reconcile both needs for no-blame and appropriate accountability, the concept of just culture is now widespread (AHRQ, 2019i).

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. There are three types of behavioral choices made by people that can lead to errors:

• Human error: A mistake or an inadvertent action
• At-risk behavior: Choices made where risk is not recognized or believed to be justified
• Reckless behavior: Choices made to consciously disregard risk, which is substantial and unjustifiable
  (Paradiso & Sweeney, 2019)

Addressing Staffing Concerns

Studies have shown that hospital patients die when the number of patients under each nurse’s care rises above an established safe maximum, which varies according to how sick they are. Nurses have noted that patient issues in hospitals and nursing facilities are becoming more complex, requiring the kind of care that was once reserved for intensive care units.

The high-risk nature of the work, stress caused by increased workload and interruptions, and the risk of burnout due to involvement in errors or exposure to disruptive behavior likely combined with unsafe conditions precipitated by low nurse-to-patient ratios result in an increased risk of adverse events.

A study conducted by Columbia University School of Nursing found an association between nurse understaffing and healthcare-associated infections in patients, demonstrating that understaffing increases the risk of HAIs.

Nurses are a constant presence at the bedside and regularly interact with all members of the healthcare team. Of all the members of the team, nurses play a critically important role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing countless other tasks to ensure patients are receiving high-quality care. It is logical that assigning increasing numbers of patients will eventually compromise a nurse’s ability to provide safe care.

Several seminal studies have shown the link between nursing staffing ratios and patient safety, showing an increased risk of patient safety events, morbidity, and mortality as the number of patients per nurses increases. On the strength of this data, several states have established legislatively mandated minimum nurse-to-patient ratios. In California, for example, acute medical-surgical inpatient units may assign no more than five patients to each registered nurse. Mandatory overtime for nurses is also restricted in 16 states.

To determine adequate nurse staffing requires a complex process that changes on a shift-by-shift basis and requires close coordination between management and nursing based on patient acuity and turnover, availability of support staff, skill mix, and many other factors.

The Magnet Hospital Recognition Program, administered by the American Nurses Credentialing Center (a subsidiary of the American Nurses Association), seeks to recognize hospitals that deliver superior patient care and, partly on this basis, attract and retain high-quality nurses. To patients, this recognition means the very best care delivered by nurses who are supported so that they can be the very best they are capable of being.

Hospital administrators should ensure adequate nurse staffing to provide the safest patient care. This could be achieved through better nurse recruitment and retention practices, together with methods of managing burnout and fatigue (AHRQ, 2019j; QPC, 2021; Columbia University Irving Medical Center, 2019).

Leadership

As the field of safety has grown, so has the recognition that organizational leadership plays a significant role in prioritizing patient safety. In the past, hospital board members have been leaders in the community who may have little or no healthcare experience. Despite being accountable for the quality and safety of the care being provided in their organization, the boards, executives, and medical staff leadership at most U.S. hospitals placed little importance on identifying and addressing issues of safety. Today there is a shift toward more direct oversight of safety and quality of care at the organizational level.

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 (walk-arounds) 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 walk-arounds, 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.

Some organizations have developed a structured approach that emphasizes early intervention by hospital leadership for clinicians who display recurrent unprofessional behavior or are the subject of multiple patient complaints (AHRQ, 2019k).