To achieve the vision of an open, transparent, and supportive culture, the Lucian Leape Institute, established by the National Patient Safety Foundation, states healthcare systems must achieve five transforming concepts: 1. Transparency must be practiced in everything they do. 2. Care must be delivered by multidisciplinary teams working in integrated care platforms (chronic care, acute care, end-of-life care, etc.). 3. Patients must become full partners in all aspects of health care. 4. Healthcare workers need to find joy and meaning in their work. 5. Health professionals’ education 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 learn and subsequently improve the system. Several strategies, such as safety reports at shift changes, appointing a safety champion for every unit, designating an administrative patient safety officer, and conducting patient safety walk-rounds and safety briefings, are some approaches to building a culture of safety (IHI, 2023). Patient safety experts also believe that to be successful, individuals at all levels, from the board of directors to managers, care providers, and patients, must contribute to a culture of safety (American College of Healthcare Executives and IHI/ NPSF, 2017). Determining the actual rate of medical errors is difficult because most estimates are based on self-report. This requires the reporter 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 represent a small portion of actual medical errors (Jeffery Woo & Avery, 2021). revised, it is still widely used to identify and analyze adverse events (Garrett et al., 2013). Although both of these tools are useful in determining whether a patient has suffered from an adverse event, they do have some limitations. For example, both tools give a retrospective focus, meaning that the event is not identified until after the patient has suffered harm. Also, both require additional review to determine if there was a preventable adverse event. Not all preventable adverse events will be identified. ● Any elopement (unauthorized departure) of a patient from a facility staffed around the clock leading to death, permanent harm, or severe temporary harm. ● An infant being sent home with the wrong family. ● On-site rape, assault, or homicide of a patient, staff member, visitor, or vendor. ● Hemolytic blood transfusion reaction caused by use of the wrong blood group. ● The wrong invasive procedure, or an invasive procedure on the wrong patient or the wrong site. ● A foreign object left inside a patient after a surgical or any invasive procedure. ● Severe neonatal hyperbilirubinemia. ● Too much radiation or radiation to the wrong part of the body. ● Unexpected death of a full-term infant. ● Abduction of a patient.
In response to the 2000 IOM report and the subsequent attention to medical errors, the focus in healthcare is transitioning 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 healthcare from individual blame to recognizing medical errors as a way to improve the system. According to the Institute for Healthcare Improvement (IHI, 2023), a culture of safety requires not only that employees work for improvement but also that they “take action when needed” (para. 1). Pressure to do the right thing comes from all directions, and inaction is unacceptable. Leaders must drive the culture of safety and create an environment in which team members believe that action will result in change instead of reprisals or mere inaction (Kerfoot, 2016). A culture of safety acknowledges the inevitability of error and proactively seeks to identify latent threats. Characteristics of such a culture include: ● An environment where individuals are confident that they can report errors or close calls and near misses without fear of retribution; ● Collaboration across ranks to seek solutions to system vulnerabilities; and ● Demonstrated willingness to direct resources to address safety concerns. (Kilcullen et al., 2022) Identifying and analyzing medical errors Improving patient safety involves recognition of errors, followed by the analysis of their root causes and contributing factors. Developing and implementing a plan to prevent or control future errors is also necessary to complete the process. Identification of errors In healthcare, it is widely known that only a small percentage of adverse events and/or near misses are reported. As a result, to improve the measurement of patient safety events in healthcare organizations, AHRQ developed a set of patient safety indicators (PSIs) that can be used with hospital discharge data to screen for potential errors (AHRQ, 2015). The PSI set includes 20 hospital-level indicators and seven area-level indicators. Similarly, in 2004, IHI developed a list of 53 triggers to identify potential adverse events that occurred during hospitalization. Though this tool has been Sentinel event The Joint Commission (TJC) defines a sentinel event as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness. Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. It should be noted that not all sentinel events are the result of an error and that not all errors result in a sentinel event (TJC, 2023b). The following sentinel events require the completion of a root cause analysis (RCA), which will be discussed next in this course: ● Suicide that takes place within a facility that is fully staffed around the clock, or suicide that takes place within 72 hours of discharge, including from the hospital’s emergency department.
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