__________________________________ Keeping Clients Safe: Error and Safety in Behavioral Health Settings
• Deference to expertise: Leaders and supervisors listen and respond to the insights of frontline staff who understand how processes work and know the risks to clients. Resilience: Leaders and staff in high reliability organizations are trained and prepared to respond when system failures occur.
• Implement critical improvement interventions without needless delay and safeguard their adoption. CASE STUDY 1 The following case example illustrates selected human factors concepts that are depicted in the Swiss Cheese Model. The scenario also compares the different ways that human error would be perceived and managed in a culture of blame versus a culture of safety. Belinda has been working in an alcohol and drug abuse clinic since she received her master of social work degree four months ago. Belinda’s supervisor, Diane, has been out of state dealing with a family emer- gency for the past week, and Belinda is sharing coverage of Diane’s caseload with the clinic’s other social worker. It has been a week of back-to-back appointments that have included several crises. On Friday, Belinda’s last appointment is with Brad, the 12-year-old son of a prominent physician. Brad’s mother called for an appointment for her son after finding marijuana in his room. She also told the intake worker that Brad had run away from home several times in the past year. During Belinda’s first session with Brad a week ago, she was frustrated and felt unable to conduct her assessment because Brad refused to make eye contact and provided monosyllabic answers to each of her questions. Brad’s mother is being treated for prescription drug addiction by the clinic’s psychiatrist, Dr. Bledsoe. The psychiatrist is supervising Belinda’s cases in Diane’s absence on an as-needed basis. Belinda, who admires Dr. Bledsoe and was excited about the opportunity to work with him, has been disappointed that Dr. Bledsoe has had no time to meet with her to discuss Brad’s case. Brad’s appearance and demeanor have changed since last week. His hair is even more disheveled now, and his eyes are red. Again, he fails to make eye contact, but now he also fidgets and refuses to speak. Fifteen minutes into the session, Belinda notices bruises on Brad’s forearm. When she asks how he got the bruises, Brad walks out of the clinic. Belinda does not know what to do. She waits outside Dr. Bledsoe’s office until his last patient leaves at 5:00 PM and then tells him that she suspects Brad is the victim of physical abuse. Dr. Bledsoe tells Belinda that he is unconcerned; he has known Brad’s parents for years. Belinda senses that Dr. Bledsoe thinks she is overreacting, but she persists. Dr. Bledsoe snaps at her, and then apologizes, explaining that he is tired. He promises to meet with Belinda on Monday to discuss her concerns. He then asks her to close the door behind her and returns to writing his notes. The clinic secretary, who is tidying her desk, sees Belinda leave Dr. Bledsoe’s office, and noticing that Belinda looks distressed, asks her what is wrong. Belinda blurts out her concern about Brad, wondering aloud if she should go over Dr. Bledsoe’s head and report her suspicions of abuse, and if so, to whom. Belinda asks if the other social worker is available, and the secretary informs her that he has gone home for the day. The secretary tells Belinda not to worry. She is certain that Belinda has done her job by informing Dr. Bledsoe.
Self-Assessment Question
1. At a monthly patient safety meeting, a frontline nursing manger suggests reducing steps used to dispense medication in an acute behavioral unit. From an HRO perspective, how should other staff present at this meeting respond to this recommendation? A) Go along with the recommendation because frontline staff are complaining about burnout B) Object to this simplification of medication distribution because it may increase patient risk C) Conduct a postdischarge survey of patients, seeking their input on this issue Take a vote of meeting members to see what the majority want Unfortunately, the predominant organization culture of blame still burdens most healthcare and behavioral health settings. This attitude delimits the growth of a safety culture because it encourages professionals to hide their mistakes for fear of being punished. A just culture of safety balances its blame-free environment with zero tolerance for blameworthy behaviors (such as impairment, felony, malfeasance, reckless behavior, and failure to learn over time), which are addressed with administrative processes that are timely and fair. This balance is known as a just culture (Seshia et al., 2018). Veazie and colleagues (2019) researched the potential applica- tion of HRO principles within the Department of Veterans Affairs for their National Center for Patient Safety. The authors published their findings from 20 HRO studies covering the period from 2010 through 2019. Upon deeper study of this research, the authors identified several HRO principles and concepts that can successfully lead healthcare organizations from concept to implementation. These strategies are: • Develop leadership. Seek commitment from board members, senior leaders, and lead providers to adopt the goal of zero harm. • Identify and build a new culture of safety. Foster trust, responsibility, and ongoing communication about unsafe patient processes and procedures, within a concerted effort to always evaluate cultural change. • Improve data systems to monitor progress, measure improvements, and share data results widely within the organization. • Commit to ongoing training and educational efforts within the organization to actively support these new organizational initiatives.
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