Safe Culture and Quality Care to Reduce Medical Errors and Promote Safety Culture

The Safe Culture and Quality Care to Reduce Medical Errors and Promote Safety Culture. A safe healthcare culture is essential to reducing medical errors and promoting high-quality care.

What Is Safe Culture and Quality Care to Reduce Medical Errors and Promote Safety Culture

This involves creating an environment where patient safety is paramount through values, beliefs, and norms shared by staff. This leads to behavior that minimizes risks and errors. This includes open communication, accountability, and a culture of fairness that encourages reporting errors without fear of blame.

Improving and Managing Safe and Quality Care

Patient safety and quality care are concepts on a continuum: Although safe nursing care results in the lowest potential to do harm to patients, high-quality nursing care results in the greatest potential to achieve the best possible patient outcomes (Galt, Paschal, & Gleason, 2011). Since the Institute of Medicine’s (IOM) groundbreaking report To Err Is Human: Building a Safer Health System was released in 2000, there has been tremendous movement toward decreasing errors and improving the safety and quality of health care (Kohn, Corrigan, & Donaldson, 2000).

Two additional IOM reports in 2004, Patient Safety: Achieving a New Standard for Care (Aspden, Corrigan, Wolcott, & Erickson, 2004) and Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004), also brought significant attention to the need to improve the safety and quality of the care delivered. However, patient safety issues present an ongoing threat to achieving quality health care, and despite significant achievements since the IOM reports were published, patients remain at risk of serious harm (Robert Wood Johnson Foundation, 2014).

In 2010, the U.S. Department of Health and Human Services reported that in a study of 780 Medicare beneficiaries, 13.5% experienced adverse events and 13.5% experienced temporary harm events during hospitalization. Further investigation revealed that at least 44% of the events were preventable. The IOM’s estimate of 44,000 to 98,000 preventable medical errors per year has been challenged by a newer report that reviewed contemporary literature (published between 2006 and 2012) to identify types and numbers of preventable adverse events in hospitals (James, 2013).

The report’s findings suggest that 210,000 to 400,000 deaths each year in hospitals in the United States are associated with preventable adverse events. Improving safety and quality in health care is not just an issue in the United States; rather, it is a global public health concern. Close to 10% of patients hospitalized in developed countries will fall victim to preventable errors or adverse events (World Health Organization [WHO], 2014a). In fact, patients are at higher risk of injury while hospitalized (1 in 300) than when flying on an airplane (1 in 1,000,000) (WHO, 2014a).

As the largest group of health-care professionals—as of 2014, there were 2,661,890 registered nurses in the workforce in the United States (Bureau of Labor Statistics, 2014)—nurses are in the key position to impact patient safety and quality care, and in fact they have an ethical obligation to promote safe and quality care. T

his obligation is reflected in Provision 3 of the ANA Code of Ethics for Nurses with Interpretive Statements: “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient” (American Nurses Association [ANA], 2015a, p. 9). Further, Provision 4 states that “nurses have vested authority, and are accountable and responsible for the quality of their practice” (p. 15). In addition, it is the mission of the International Council of Nurses (ICN) “to ensure quality nursing care for all and sound health policies globally” (2014, para. 1). The ICN also believes that nurses must ensure patient safety in all aspects of care delivery. According to the ICN, promoting patient safety:

involves a wide range of actions in the recruitment, training and retention of health care professionals, performance improvement, environmental safety and risk management, including infection control, safe use of medicines, equipment safety, safe clinical practice, safe environment of care, and accumulating an integrated body of scientific knowledge focused on patient safety and the infrastructure to support its development (ICN, 2012, para. 1).

Although the nursing profession has an obligation to take the lead in the patient safety and quality movement, nurses need to do more than they have in past decades if there is to be progress (Johnson, 2012). Further, it discusses the roles of nurses at all levels in ensuring patient safety, from developing a culture of safety to standardizing processes, and improving patient safety, including using safety initiatives and incorporating tools for quality improvement (QI). Knowledge, skills, and attitudes related to the following core competencies are included: patient-centered care, teamwork and collaboration, QI, and safety.

Medical Errors

Health care is becoming more complex, and along with increased complexity comes the growing problem of medical errors. The IOM defines a medical error as “the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error in planning)” (Kohn, Corrigan & Donaldson, 2000, p. 28). An injury to a patient caused by medical management rather than the patient’s underlying condition is called an adverse event or a patient safety event (The Joint Commission [TJC], 2016a), and most of these events are preventable.

Several highly publicized cases of preventable medical errors spurred numerous initiatives to pro mote patient safety and improvement of quality of care. Table 7-1 illustrates some of these incidents related to preventable errors and the policy outcomes that resulted. There are two types of errors: an error of omission and an error of commission. An error of omission results when an action is not taken or omitted, such as when a nurse does not assess a patient after surgery or does not administer a medication; in both situations, the nurse omitted an action that is a standard of care.

An error of commission results when the wrong action is taken or committed. Examples of errors of commission include a nurse giving a medication to the wrong patient or per forming a procedure incorrectly (e.g., a nurse breaking sterile technique when inserting a Foley catheter). When an error occurs in the presence of a potential hazard, it is an unsafe act (Reason, 1990). Some unsafe acts do not result from errors but from violations. A violation is a deliberate deviation from safe practices as identified by designers, managers, and regulatory agencies to maintain a safe system (Reason, 1990).

For example, a common standard of care is that nurses must check a patient’s name band before medication administration; neglecting to check a patient’s name band before administering medications is a violation. Errors and violations do not always result in harm or accidents. However, they have the potential to do so. Further, errors can be classified as slips, lapses, and mistakes (Reason, 1990). Slips and lapses are execution failures—in other words, they occur from actions that do not result in the intended outcome.

Slips are observable by others (e.g., a nurse documenting that she gave a medication on the wrong patient’s chart), whereas lapses usually involve memory failure and may be apparent only to the person experiencing the failure (e.g., a nurse forgetting to administer a medication but not documenting it anywhere). Mistakes are errors that occur when an action goes as planned but the action is incorrect. Mistakes are subtler and more complex than slips or lapses. As a result, mistakes are often difficult to detect and pose a greater danger to patients than slips or lapses (Reason, 1990).

For example, a nurse is told by unlicensed assistive personnel (UAP) that a patient’s temperature is elevated. The nurse checks the patient’s chart for an order and administers medication for the fever. Later, the nurse realizes that the UAP told her that the wrong patient had the elevated temperature, and so the nurse gave the medication to a patient who had an order but did not have an elevated temperature. This constitutes a mistake because the action was taken with the incorrect patient, and therefore the action was incorrect.

To truly ensure safety, any near miss, or a potential error that was discovered before it was carried out, must be monitored. For example, a nurse enters a patient’s room to administer a medication and realizes that it is the wrong patient. She immediately leaves the room with the medication and avoids the commission of an error. In this situation, a near miss occurred and should be investigated to avoid an actual error in the future.

A sentinel event is a patient safety event that results in any of the following: death, permanent harm, and severe temporary harm and intervention required to sustain life (TJC, 2016c, para. 2). A sentinel event signals “the need for immediate investigation and response” (TJC, 2016a, para. 4). Sentinel events are tracked by TJC. However, reporting a sentinel event is voluntary. Human errors can be viewed from two perspectives: the person approach and the systems approach (Reason, 2000).

The person approach focuses on unsafe acts of health-care professionals and errors as the result of human behaviors, such as inattention, forgetfulness, negligence, and incompetence. Organizations that focus on the person approach often attempt to correct human behavior through naming, blaming, shaming, and retraining. The systems approach, however, acknowledges that errors happen because humans are not perfect. With this approach, the focus is less on the individual making the error and more on system processes that led to the error. In fact, errors are expected, and many defenses are in place to safeguard against them.

Organizations that focus on the systems approach concentrate on changing the work environment by establishing barriers and safeguards against the errors (Reason, 2000). Highly educated and competent nurses make errors; human factors can provide explanations for these errors. Unintentional human errors and system errors account for most preventable adverse events (Denham, 2007). Although most errors have multiple causes, the most common are related to human factors, communication, and leadership (Shepard, 2011):

Human factors include staffing levels, staff education and competency, and staffing shortages. When staffing is inadequate or nurses lack experience, patient safety is jeopardized.
Communication includes intra-professional and inter-professional communication as well as interactions with patients and their families. Optimal patient outcomes rely on effective communication.
Leadership includes leadership and management at all levels, organizational structure, policies and procedures, and practice guidelines. When leadership factors are inadequate, nurses may make decisions that can result in adverse events or near misses.

Preventing errors and adverse events relies on a systems approach that reduces the likelihood of patient safety events. Nurse leaders and managers must be able to follow through with the following activities to ensure patient safety (Galt, Paschal, & Gleason, 2011, pp. 8–9):

Develop a culture that is founded on the concept of safety for both patients and staff.
Standardize as many processes as possible while simultaneously allowing staff the independent authority to solve problems in a creative manner as well as avoiding automatic action.
Implement initiatives created by health-care organizations to improve safety and quality.
Analyze complex processes by using appropriate tools.
Collect data on errors and incidents within the unit to identify opportunities for improvement and track progress.

Creating A Culture of Safety

A culture of safety is a blame-free environment in which staff members feel comfort able reporting errors and near misses. Until the early 2000s, when an error was made by a nurse, the approach by management was punitive and involved identifying the individual who made the error and requiring that he or she to be named in an incident report and complete a medication review course. This approach did not seek the root cause of the error and was not effective in reducing errors.

Sadly, this approach still occurs today. A culture of safety supports nurses in that it is no punitive and emphasizes accountability, excellence, honesty, integrity, and mutual respect (Johnson, 2012). In a culture of safety, patient and employee safety is the priority, and organizational leadership is committed to providing safe and quality care as well as creating a safe work environment. A culture of safety develops over time and includes three stages (Page, 2004, pp. 296–298):

Stage 1. Safety management is based on rules and regulations: The organization sees safety as an external requirement imposed by regulatory bodies, and mere compliance with rules and regulations is considered adequate.

Stage 2. Good safety performance becomes an organizational goal: Safety is perceived by leadership and management as important, but safety performance is addressed in terms of goals rather than as part of the strategic plan and culture of the organization.

Stage 3. Safety performance is seen as dynamic and continuously improving: Safety performance is viewed by everyone in the organization as dynamic and in need of continuous improvement in this stage. There is a strong emphasis on communication, training, management style, and improving efficiency and effectiveness.

A culture of safety promotes staff engagement and empowerment and focuses on why an error was made rather than who made the error. Embedded within a culture of safety is a just culture, or a culture that is fair to those who make an error. A just culture improves patient safety because it encourages nurses to learn from each other’s mistakes and to report all errors and near misses without fear of repercussion. Nurses are responsible for their own actions and are expected to provide constructive feedback to their peers (Shepard, 2011; Wachter, 2012).

Nurse leaders and managers are responsible for promoting a culture of safety and creating an environment where nursing care is delivered safely and effectively (ANA, 2015b). Creating a culture of safety is hard work; however, once a culture of safety is established, “it is easy to identify its presence, as well as its absence” (Wachter, 2012, p. 275).

Part of creating a culture of safety is encouraging staff members to voice their concerns when they feel that a situation is a safety risk. This can be done through a communication technique called “CUS,” a three-step process that assists staff members in stopping an activity when they sense or discover a safety breach. CUS stands for the following (TJC, 2012, p. 52):

I am Concerned.
I am Uncomfortable.
This is a Safety issue.

Further, nurse leaders and managers can “promote a process of mistake or error mitigation that recognizes that errors may be the result of system breakdowns or failures to build a good system, as opposed to putting the total blame on individuals” (ANA, 2015b, p. 6).

A culture of safety relies on a systems approach that reduces the likelihood of patient safety events. A key aspect of preventing errors and adverse events is to avoid automatic actions. As nurses become experienced with a specific task, cognitive adaptive mechanisms kick in and allow for nurses to go on “autopilot” (Galt, Fuji, Gleason, & McQuillan, 2011). Unfortunately, this ability to take complex skills and make them routine can negatively impact patient safety.

As tasks and skills become automatic, nurses pay less attention to details, and this deficit can result in variations in care and the possibility of a patient safety event or error. Evidence shows that varying patterns of care lead to poor clinical outcomes. In contrast, standardizing care can improve clinical outcomes, reduce inefficiencies, and decrease costs (Tsakos et al., 2014). Nurse leaders and managers can intervene by ensuring that nurses use standardized procedures and checklists rather than relying on memory and automatic approaches to patient care.

When there are variations in processes and procedures, confusion, delays in care, and varying levels of nursing care quality can result. Standardizing processes and procedures can help reduce errors and improve quality care. Standardization is the process of developing, agreeing on, and implementing uniform criteria, methods, processes, designs, or practices that can improve patient safety and quality of care (Tsakos et al., 2014). Standardized processes benefit health care by:

Providing nurse leaders and managers and nursing staff with a method for com paring outcomes resulting from standardized processes across the organization
Enabling nurse leaders and managers to compare data and interpret relevance and efficacy of a specific intervention or process
Allowing for a way for nurses at all levels (as well as other health-care professionals) to communicate with one another in meaningful ways (i.e., use of standardized terms)
Increasing the likelihood of user familiarity with technology and equipment that can reduce risk of human errors
Allowing nurses at all levels as well as other health-care professionals to learn from each other’s experiences

Standardization can take many forms including using checklists, approved abbreviations and practice guidelines, electronic health records, and computerized physician order entry; storing equipment and supplies in the same location on units; and designing units using the same floor plan within a facility. Although a challenge, nurse leaders and managers must standardize as many processes as possible while simultaneously allowing staff the independent authority to solve problems in a creative manner.

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