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Culture of Safety
IHC, in cooperation with health care providers across the state, has developed the following Culture of Safety Toolkit. The toolkit is a compilation of resources to ensure that patient safety remains at the forefront of every facility’s plan for effective and safe patient care.
We would like to thank those individuals and organizations who have shared their materials and who have agreed to serve as mentors. Please contact IHC if your organization would like to contribute additional materials to this toolkit.
Case for Change
Background
Modern health care is a highly complex, high-risk, and error-prone activity. Not
surprisingly, adverse health care events are a leading cause of death and injury. Despite
remarkable advances in health care technology and delivery, too many patients die or are
disabled as a result of adverse health care events. Adverse health care events occur in all
health care settings: hospitals, clinics, nursing homes, urgent care centers and surgery
centers.
The Institute of Medicine's report, To Err is Human, projected between 44,000 and
98,000 deaths annually secondary to preventable medical errors in our hospitals. The
higher estimate of 98,000 deaths ranks medical errors as the fifth leading cause of death
in the United States – higher than motor vehicle accidents (43,458), breast cancer
(42,397), or AIDS (16,516).
Preventable injury resulting from medical errors cost the economy from $17 billion to
$29 billion annually, half of which are health care costs.
One in five Americans (22%) reported that they or a family member has experienced a
medical error of some kind. Nationally, this translates to an estimated 22.8 million
people with at least one family member who experienced a mistake in a doctor's office or
hospital.
Of those experiencing a medical error, 10% reported that they or a family member
had gotten sicker, and about half of those said the problem was serious. Nationally, this
means that an estimated 8.1 million households reported a medical mistake that was very
serious.
Patient Safety
Patient safety is simply defined as "the prevention of harm to patients." Patient safety is
an integral part of the delivery of quality of care and a fundamental right of all
Americans. Although simple in definition, the road to ensuring patient safety in health care facilities is complex and replete with obstacles.
Health care organizations should make patient safety a declared and serious aim by
establishing comprehensive patient safety programs with defined executive
responsibility, operated by trained personnel and in a culture of safety.
Patient safety programs should:
- Provide strong, clear and visible attention to safety.
- Implement a just system for reporting and analyzing errors within their organizations.
- Incorporate well-understood safety principles (such as best practices).
- Establish interdisciplinary team training programs for providers that incorporate proven methods of team training such as simulation.
- Identify and analyze system failures such as medical errors and near misses.
- Provide proactive evaluation and redesign of systems to improve care processes to prevent future errors.
- Involve participation of patients and their families and be responsive to their inquiries.
- Communicate findings throughout the organization in a consistent manner.
- Provide education related to patient safety science.
The information presented should be treated as a gateway and a toolkit. Each element provides basic information which is then followed by resources (books, journal articles and websites) for further review or investigation. There is no one right way in the development or evaluation of a patient safety program. Therefore, take what is useful and applicable and leave what is not.
The information contained is provided as advisory and is not meant as an endorsement of any particular methodology or website, but only as a collection of resources for consideration and use.
Sources:
- Safe Practices for Better Healthcare, Kizer K. National Quality Forum (NQF) 2003.
- Quality of Health Care in the United States: A Chartbook, Sheila Leatherman, Ph.D. and Douglas McCarthy, The Commonwealth Fund, April 2002.
- Institute of Medicine (US). To Err is Human: Building a Safer Health System. Washington (DC): National Academy Press; 2000.
- The Commonwealth Fund 2002
- Institute of Medicine (US). Patient Safety Achieving a New Standard for Care. Washington (DC): National Academy Press; 2004.
Project Description
Objectives
Transforming the organizational culture is critical to improving patient safety. The trend of providers focusing on learning from past mistakes rather than pointing the finger when something goes wrong is positive. Components of a safe culture include:
- Patient Safety Dialogues
- Blameless Reporting
- Engaged Leadership
Project Team
The project team consists of physicians, nurses, and Iowa experts in patient safety. The resource team for this project also includes representatives of the Iowa Foundation for Medical Care and the VA Central Iowa Health Care System.
Status
The development of this toolkit, combined with IHC's 2007 culture of safety strategy, will help provide a solid framework for provider improvement in patient safety.
Tool Kit
Patient Safety – Human Error and Improving Patient Care
Leadership Engagement
Culture Assessment Tools
Just Culture
A Just Culture is a method used to create a positive culture for patient safety. Created by David Marx, a system safety engineer, the original intent of the concept was to develop a system to fairly define culpability for potential or actual harm due to medication errors.
For approximately ten years, the Just Culture Community has been working to develop open, fair, and just cultures that support open communication and development of systems for accountability.
One goal of a Just Culture is to assign consequences for an unsafe act in a fair way. Four key categories of a Just Culture to assign fault include:
- Human error: unintended mistake
- Negligence Conduct: failure to exercise care
- Reckless Conduct: conscious disregard for a known risk
- Knowing Violations: conscious disregard for known rules
Many health care facilities are beginning to implement the Just Culture approach to reduce errors, reduce medical harm, and improve patient safety.
Improvement of Infrastructure and Capability
Success Stories
Belmond Medical Center, Belmond, IA
Belmond Medical Center had an opportunity to improve the care of patients presenting to our ER. One of the most important things we do, as a CAH facility, is triage and transfer patients to provide them with the best outcome. As a result, we are focus-centered on how we can improve the transfer time for patients experiencing chest pain, namely improving the time to diagnosis by reducing the time between arrival and EKG.
With a goal of 10 minutes from entry into the system for an EKG, our door to EKG times for the proceeding months were evaluated. The average times for the past several months were respectively 17.8, 16.9, 19.9, 33.5, and 22.7 minutes. With this information in hand, the objective was to create a program for the nursing staff and allow providers to gain an awareness of our present door to EKG time and reinforce the need for obtaining rapid EKG's.
The "Door to EKG" program consisted of:
- A presentation and discussion for nurses and providers including:
- Education – statistical information related to cardiac events, and the "Time is Muscle" concept
- BMC time statistics for the past several months
- Ways to initially reduce the time
- A commitment from staff for the need to make this a top priority
- Setting next steps
- Development of a team to discuss physical and environmental barriers to success (including a provider and a nurse representative from each shift)
- A commitment to monitor progress and provision of routine progress reports
The presentation was initially met with some disbelief of the door to EKG times. This realization and awareness of the effects was truly the key to change. The reinforcement of the cause and effect was important for staff. Nurses immediately began to focus on the early EKG in association with aspirin and oxygen as the basics. Other early changes were associated with physical placement of the EKG machine and staff training. During off hours, when nursing did not have the services of lab readily available to perform the EKG's, the EKG machine was moved into the ER where it was available. Training was provided to nursing staff so all were able to perform EKG's in the absence of help from the lab.
As per the commitment, reports were provided at nurses' meetings on a monthly basis in two variations. One variation showed each individual EKG time and the other demonstrated the Suzan Brunes average EKG time for the month. This information enabled us to analyze any particular outliers.
Although we have very few EKG's on a monthly basis, we have demonstrated follow through on our commitment to reduce our door to EKG time so that, "100% of people will have the potential for less heart damage every year" as they come through our Emergency Department. Since the December presentation, changes have been made, training completed and our Door to EKG time has been below 10 minutes each month.
Belmond Project Data Sheet
Mentor Hospitals
Dan Varnum, Mercy Hospital DSM
Janelle Rynearson, Patient Safety Officer, Central Iowa VA DSM (VA NCPS trained)
Kimberly Gau, CEO, Guttenberg (Stanford University pt safety program trained)
Resources
Websites
Patient Safety Organizations
Governmental Agencies
Medication Safety
Professional Associations
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