Creating a just safety culture - Patient Safety First

AORN Journal,  Feb, 2004  by Suzanne C. Beyea

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Clinicians often talk about the culture of their hospital, OR, or ambulatory setting. What comprises that culture? Generally speaking, culture is the shared values, attitudes, and beliefs that exist within a specific organization. Recently, experts have suggested that health care organizations should create a culture of safety. Achieving this goal does not simply mean that clinicians need to be more careful and make fewer errors.

A JUST ENVIRONMENT

Integral to establishing a culture of safety is creating a just environment. Within such an environment, clinicians and other staff members are encouraged, supported, and rewarded for promoting safety-related efforts and reporting errors. (1) To create a just environment, the nature of medical errors must be understood and error reporting valued. Clinicians and administrators must acknowledge that error-prone situations develop because of the complex nature of health care systems. There also must be a clear understanding that clinicians will make mistakes, and such errors occur as the result of underlying system failures. (2)

In a just environment, clinicians and other staff members understand that they can discuss or report errors without fear of punishment or reprisal. Errors and near misses need to be reported and studied. Most nurses can recall a time when they discovered or were aware of an error but did not report it because they did not want to get a colleague in trouble. Traditionally, medical errors have been considered performance problems that can be addressed by counseling, retraining, reeducating, and restricting practice. Blame is placed on the clinician without consideration of the factors contributing to the error.

FACTORS THAT LEAD TO ERRORS

Most clinicians have been involved in some type of medical error. Many nurses recall the first medication error in which they were involved. Typically, a nurse might comment, "I was so stupid," "I was careless" or "I didn't follow the policy." Rarely do nurses describe or discuss how system-related errors might have contributed to the error. For example, perioperative nurses might make an error when accessing an automated dispensing device for a medication. If different doses of the same medication are in the same drawer, it might be easy to grab the wrong dose or strength. An error also could occur if a pharmacy staff member misfilled the drawer or cassettes. Of course, nurses should verify the label on any vial or ampule. Labels, however, may be difficult to read or misleading and, thus, contribute to confusion. Medications also may have similar names or packaging, which can lead to misreading a label.

Errors involving medications, such as epinephrine, can and do occur. Epinephrine comes in multiple strengths and concentrations and often is dispensed in combination with other medications (eg, local anesthetics). Confusion can relate to the fact that epinephrine is labeled using its strength (eg, 1:1,000; 1:100,000) and not the milligram per volume convention used with other medications. These factors can present a higher risk if a caregiver is rushed, tired, distracted, or under pressure during an urgent or emergent situation. Environmental and situational factors, such as poor lighting, noise, or interruptions, can negatively influence clinician performance. All of these conditions contribute to errors at the "sharp end" where clinicians provide care and interact with patients.

A SYSTEMS APPROACH

Rather than blaming staff members involved in an error, health care facilities must examine how systems contributed to a specific error. Using a systems approach, facilities can enhance their reliability and, thus, reduce error potential. Decisions made by managers, equipment designers, architects, and others that contribute to error-producing or latent conditions at the "blunt end" of care processes can be identified and addressed when systems are examined.

The work environment can be redesigned to minimize factors that contribute to errors. Making it impossible for an error to occur by using forcing functions or making it difficult to make an error through the use of constraining functions can help reduce errors at the sharp end of care. For example, a forcing function exists when intravenous potassium is removed from floor stock and clinicians do not have access to it until a pharmacist has reviewed the order and dispensed the medication. An example of a constraining factor involves the use of a device that does not allow a clinician access to a unit of blood before he or she has verified the blood unit number. When systems are designed to eliminate or reduce errors, safety is enhanced. Some additional strategies that have been identified as key to creating a culture of safety include

* simplifying tasks and reducing hand-offs,

* redesigning work processes,

* reducing the need for calculation,

* providing adequate training,

* including human factor design principles in clinical processes,

* decreasing reliance on vigilance and memory, and