Keeping Clients Safe: Error and Safety in Behavioral Health Settings _ ________________________________
CULTURE OF SAFETY AND HIGH RELIABILITY ORGANIZATIONS The concept of a safety culture originated outside of health- care and emerged from studies of high-risk industries such as nuclear power, aerospace, and aviation. Researchers identified a culture of safety embedded within what they called a high reliability organization (HRO), which is best described as a complex organization that engages in high-risk activities but experiences few catastrophes (Oster & Braaten, 2021). Despite its hazardous environment, an HRO operates for long periods of time without catastrophe because of its “error-tolerant” cul- ture, which means that it recognizes the futility of eliminating human error and designs work processes in which errors can occur without leading to disaster. Below are some of the charac- teristics of HROs as they might relate to behavioral healthcare. HROs create a culture of safety by first acknowledging the risky nature of their activities and then operate to effectively manage risky situations through organizational control and the ongoing calculation of probabilities of error. Clearly, this approach is typified by facing risks, understanding them, and trying to anticipate their probable occurrence. Moreover, the HRO will seek to identify weaknesses within their system and create management and process steps to miti- gate these risks. A culture of safety encourages—and actively fosters within an HRO—collaboration across ranks, disciplines, specialties, and departments to solve safety problems. The HRO focus is on teamwork to proactively identify latent (hid- den) vulnerabilities (Oster & Braaten, 2021). A culture of safety is committed to learning. In a culture of safety, adverse events and near misses (close calls) are viewed as opportunities to improve the system. For this type of learn- ing to occur, the organization must develop an atmosphere of trust that encourages workers to report adverse events and near misses. In this transparent, supportive reporting culture, workers are confident that they can report problems without being punished. When something bad happens, the focus is on what happened rather than who did it. Oster and Braaten (2021) define HRO principles as follows: • Sensitivity to operations: Systems and processes that affect client care are constantly assessed to prevent risks. • Reluctance to simplify: Simplistic explanations of failure (e.g., unqualified staff, inadequate training, communication failure) are avoided, and underlying factors that place clients at risk are explored. • Preoccupation with failure: Near misses are viewed as “symptoms,” that is, evidence that an area or work process needs to be improved to reduce potential harm to clients.
• Cognitive overload that impairs the individual professional Patient-related factors that impact human error include: • Communication challenges (e.g., language barrier and cognitive dysfunction) • Adherence (compliance and concordance with medical advice) • Cognitive-affective biases of patients that influence personal healthcare decisions (same as biases listed above) UNDERSTANDING ORGANIZATIONAL CULTURE The difficulty of culture is that it an abstraction, culled and cre- ated—at minimum-- from the milieu of subjective attitudes and behaviors of people, both individuals and groups. Moreover, there are varying definitions of what culture exactly is. It is real, but it is veiled, somewhat invisible. The visible effects are seen within the patterns of thought and behavior that the group demonstrates most often. Because of these characteristics, culture can often be unquestioningly accepted, followed, and continued by people. This can be a problem within groups. Organizational culture is no different from our larger human and societal culture (Oster & Braaten, 2021). Oster and Braaten (2021) point out that researchers who study organizational culture use several defining characteristics to help identify the elusive nature of organizational culture. • It does really exist. • It is characterized by ambiguity. • It can be malleable and specific. • It is the result of group interactions and is thus a social construction. • It exists in healthcare. Furthermore, there are drivers and factors that ultimately cre- ate or contribute to the creation of a specific organizational culture. One of these factors is identified as an artifact, namely processes and structures that have survived and existed within the organization for a considerable amount of time. These artifacts can be the direct result of espoused positions or goals of the organization that have also had a considerable life span, adopted and repeated by successive groups of lead- ership, providers, and frontline staff. Additionally, much of organizational culture can often be further linked to conscious and unconscious assumptions held within the organization by current staff or previous staff. Certainly, organizational culture is palpable, sometimes powerful, but this milieu of historical and assumptive factors can make it more difficult to objectify, study, and change (Oster & Braaten, 2021).
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