Keeping Clients Safe: Error and Safety in Behavioral Health Settings _ ________________________________
In addition to participating in safety briefings, mental health professionals can contribute to the culture of safety in their organizations by committing to a personal practice of being mindful of the language they use, for example, asking “What happened?” rather than “Who did it?” when something goes wrong. The importance of culture can- not be overemphasized (Montague et al., 2019). In the years since the publication of the IOM report, there have been countless initiatives to develop and implement safe practices and to train healthcare workers in patient safety at the local, national, and international levels. Despite these efforts, health- care organizations are still striving to improve safety and will continue to do so until the culture is transformed. ROOT CAUSE ANALYSIS Root cause analysis is a structured problem-solving method that was initially developed to analyze industrial accidents. It is designed to look beyond the immediate outcome, that is, active failures that occur at the sharp end (the point of interface between humans and a complex system) to expose blunt end problems (the latent failures hidden within the system) that contribute to adverse events. When a sentinel event occurs, a root cause analysis seeks to identify not only what happened but also why it happened and what can be done to prevent it from happening again. A root cause analysis is the structured process of questioning why a sentinel event occurred; it uncovers information that is then used to develop strategies to prevent another adverse outcome (Oster & Braaten, 2021). Unfortunately, researchers assert that root cause analysis (RCA) programs and their effects on patient safety are not well understood. Studies reveal that RCA has great potential in healthcare settings; however, researchers point out the spe- cific context in each setting and the effort to customize RCA process are key factors for creating value potential (Peerally et al., 2017). Nonetheless, all behavioral health organizations that participate in The Joint Commission’s accreditation program are required to conduct a root cause analysis follow- ing a sentinel event (defined by The Joint Commission as any unanticipated event that results in death or serious physical or psychological injury and that is unrelated to the patient’s illness). The following list identifies The Joint Commission’s requirements for a thorough and credible root cause analysis. According to the U.S. Department of Veterans Affairs (2014),
increasing an organization’s capacity to respond correctly in critical moments (Deng et al., 2019). Another strategy for improving patient safety is transitioning from red rules to more flexible safety imperatives. The category of red rules is an absolute; in other words, a red rule is a class of rules that can- not be broken. However, as Oster and Braaten report (2021), when studied, red rules revealed an organizational culture that featured blame and corrective actions. Transitioning from strict red rules to flexible safety imperatives helps frontline staff feel more at ease with reporting safety issues, providing feedback, and learning about key safety imperatives within the organization. Safety Every Day The daily safety briefing is a structured method for transferring unique knowledge—something learned by a single clinician when doing a particular task—to the larger work group so that the lesson can be understood by the entire team and integrated into existing work processes and used when a similar situation occurs. The safety briefing makes unspoken knowledge explicit among team members and also helps the team itself learn from its own experiences. A nonjudgmental attitude can create a space that is free of fear, establishing the ideal milieu for this type of briefing (Montague et al., 2019). Safety briefings are facilitated by unit staff and are most suc- cessful when held on a regular basis, either scheduled at the same time every day or after some defined unit of work, such as individual or group therapy sessions (Castro-Rodriguez et al., 2020). Routine, frequent meetings are easier to keep brief and focused. Also, frequent meetings are critical because the more frequently these safety briefings occur, the more com- fortable staff members become in learning from experience without placing blame. When an adverse event does occur, everyone involved in direct care should attend the safety briefing to fully under- stand what happened and to brainstorm ideas about how to integrate the learning into future actions. Notes taken during the briefing are informal and not forwarded to supervisors so that staff members feel free to share knowledge without fear of embarrassment or recrimination. One person is assigned to take responsibility for any needed follow-up. Some of the key features of a safety briefing include the following. • Involving everyone who provides direct care, led by a senior clinical provider • Scheduled daily meetings that are brief (15 minutes) • Asking critical questions: ○ What happened to threaten client safety? ○ What should have happened? ○ What accounted for the difference? ○ How can the same outcome be avoided next time? ○ What is the follow-up action plan?
an RCA must accomplish the following criteria. • Identify human factors (such as distraction,
communication failure, and fatigue) and processes and systems most directly associated with sentinel events or close calls • Analyze underlying cause-and-effect systems through a series of “why” questions to determine where redesign of a work process might reduce risk • Identify risks and their potential contributions to the adverse event or close call
12
EliteLearning.com/Psychology
Powered by FlippingBook