A CULTURE OF SAFETY: IDENTIFYING, ANALYZING, AND REPORTING MEDICAL/DENTAL ERRORS Building a culture of safety
In response to the 2000 HMD report and the subsequent attention to medical/dental errors, the focus in health care has gone from blame to recognizing that errors can occur at any point in the healthcare delivery system. Making errors visible, studying their causes, and designing methods to improve the system represent a major shift in health care from individual blame to recognizing medical/dental errors as a way to improve the current system. The Institute for Healthcare Improvement (IHI, n.d.) defines a culture of safety as one in which “staff members are aware of safety issues and are free to report conditions that could lead to near misses or actual adverse events. This open exchange of information requires the management to have a non-punitive response philosophy that rewards reporting of safety issues and events and does not punish staff members involved in errors or adverse events related to system failures.” The National Patient Safety Foundation established the Lucian Leape Institute to provide strategic guidance for achieving safe health care (Leape et al., 2009). The institute describes a culture of safety as one that is “open, transparent, supportive, and committed to learning where doctors, dentists, nurses, and all health workers treat each other and their patients competently and with respect; where the patients’ interests are always paramount; and where patients and their families are fully engaged in their care” (p. 425). Leape and his associates (2009) maintain that safety does not depend on measurements, practices, and rules, but on achieving a culture of trust, reporting, transparency, and discipline – a culture of safety. Whereas errors define the boundaries of safe practice, the cultural focus must be on preventing blame. These principles must permeate every level of the organization (Morath, 2008). To achieve this vision, the Lucian Leape Institute states that healthcare systems must achieve five transforming concepts: 1. Transparency must be practiced at all times. 2. Care must be delivered by multidisciplinary teams working in integrated care platforms (chronic care, acute care, Identifying and analyzing medical/dental errors Improving patient safety involves recognition of errors, followed by the analysis of the root causes and contributing factors. Developing and implementing a plan to prevent or control future errors is also necessary to complete the process. Determining the actual rate of medical/dental errors is difficult because most estimates are based on self-reports. Self-report requires individuals to identify that an error has occurred, recognize that it is a reportable event, and not fear repercussions from reporting the event. These “incident” reports uncover only a small portion of actual medical/dental errors (Wachter, 2012). Identification of errors To improve the measurement of patient safety events in healthcare organizations, AHRQ (2005, 2006) developed a set of Patient Safety Indicators (PSIs) that can be used with hospital discharge data to screen for potential errors. The PSI set includes 20 hospital-level indicators and 7 area-level indicators. The IHI developed a list of 53 “triggers” with a similar purpose – to identify potential adverse events that occurred during hospitalization (Griffin & Resar, 2009). Both of these tools are useful in determining whether a patient has suffered from an adverse event; however, these tools have limitations because they: ● Are retrospective, meaning that the event is not identified until after the patient has suffered harm. ● Require additional review to determine if there was a preventable adverse event. ● Will not identify all preventable adverse events.
end-of-life care, etc.). In dentistry, comprehensive care would involve proper referral to specialists and physician consultations. 3. Patients must become full partners in all aspects of health care, including oral health. 4. Healthcare workers need to find joy and meaning in their work. 5. Health professionals’ education – including that of oral healthcare professionals – must be redesigned to prepare new care providers to function in the new environment (Leape et al., 2009). In a culture of safety, errors are viewed as opportunities to improve the system. As cultural changes do not occur quickly, the efforts on the part of all healthcare providers must be consistent and sustained (IHI, n.d.). Several strategies, such as safety reports at shift changes, appointing a safety champion for every unit, designating a patient safety officer with a position in administration, and conducting patient safety walk-arounds and safety briefings, are some approaches to building a culture of safety (IHI, n.d.). This strategy can be made applicable to a private dental practice by the appointment of a staff member as the safety coordinator to oversee patient safety issues and present current issues and reviews in patient safety relating to dentistry. Patient safety experts also believe that to be successful, all individuals at all levels (including patients) must contribute to a culture of safety (U.S. Department of Veterans Affairs, 2014a). One of the features of a culture of safety is the emphasis on full disclosure to patients after a medical error has occurred. Although this remains difficult, experts have stressed the need to apologize to patients and their families for errors (Leape, 2006). Full disclosure involves telling the patient and family what went wrong and explaining steps to prevent future errors (Straumanis, 2007). Although patient participation is key, it is important to remember that the responsibility to provide safe care rests with providers and healthcare organizations. Root cause analysis Root cause analysis is a widely used structured method of identifying the causal and contributing factors underlying adverse events with the continuing goal of preventing recurrence. Root cause analysis is done after an error occurs and is designed to uncover problems that resulted in an adverse patient event. The process of root cause analysis looks beyond the immediate result and strives to identify the chain of events and contributing factors that led to the error. The purpose is to identify what happened, why it happened, and what can be done to prevent it from happening again, by examining both the active and latent errors that occurred. Root cause analysis is based on the premise that most human errors are fostered by system failures, and that personal blame is less helpful than assessing how to prevent future errors (TJC, 2010). Since 1997, the Joint Commission has required that a root cause analysis be conducted for each reported sentinel event – that is, an event that resulted in death or physical or psychological injury (TJC, 2013). The Joint Commission standards require that a root cause analysis be thorough and credible. Table 1 summarizes the requirements for a thorough and credible root cause analysis. Experts from all areas involved in the adverse event and those individuals who are familiar with the situation should be included in the process. The main premise of root cause analysis is that systems and events are interrelated. An action in one area triggers an action in another. The basic types of root causes include:
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