A CULTURE OF SAFETY: IDENTIFYING, ANALYZING, AND REPORTING MEDICAL ERRORS This section reviews the components of a safety culture and describes tools used to identify, analyze, and report medical errors. Building a culture of safety
● Collaboration across ranks to seek solutions to system vulnerabilities; and ● Demonstrated willingness to direct resources to address safety concerns. (Kilcullen et al., 2022) 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.
A body of literature suggests a link between the culture of an organization and the safety of patients. Organizations associated with decreased harm to patients include the following characteristics: a strong culture that embraces teamwork, in which speaking up about concerns is the norm; dedicated systems, structures, and processes that allow for the sharing of concerns; and the identification of actions implemented that result in safety improvements before the act reaches the patient (Kilcullen et al., 2022). Essentially, a strong safety culture is linked to fewer adverse events, while an organization with a weak culture is associated with higher rates of adverse events (Amiri et al., 2018; Rodziewicz et al., 2023). 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; 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
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