Every organization needs a structure and a tool kit to support employee and patient safety and continuous quality improvement. Since what cannot be seen cannot be fixed, robust identification of adverse events and latent safety threats (risk to patients, families, and employees) should be a priority of every hospital. Here, we discuss structures and tools to identify adverse events and risk. Once identified, the hospital and staff must then prioritize efforts and determine which techniques will be applied to reduce adverse events and risk. Risk reduction efforts may focus on error prevention or on harm prevention, and both approaches are key to risk reduction. Table 19-1 reviews definitions for the key terms used throughout the chapter.
TABLE 19-1Common Terms Used to Describe Errors and Harm ||Download (.pdf) TABLE 19-1 Common Terms Used to Describe Errors and Harm
|Term ||Explanation |
|Adverse event ||Harm resulting from medical care |
|Preventable adverse events ||Harm due to medical care that could have been avoided |
|Latent safety threat ||Factors that make error more likely but are not directly visible; also called blunt error |
|Near miss ||Error occurs but does not reach the patient |
|Sentinel event ||Unexpected death or serious harm or risk thereof |
|Adverse medication event ||Error resulting from medication-related interventions |
|Slip ||Failure of execution in which the technical action is observable |
|Lapse ||Failure of execution typically due to memory failure |
THE ROLE OF THE CULTURE OF SAFETY IN IDENTIFYING RISK
In organizations with a robust culture of safety, it is evident to all involved that safety is the top priority. People working in the area focus on safe practices and support one another in delivering safe care. Individuals in a mature culture of safety exhibit the principles of a highly reliable organization, including “preoccupation with failure” as described by Weick and Sutcliffe, such that there is a constant obsession with mitigation of risk. Instead of ignoring small, nagging concerns, workers share those concerns with others, and team members rally to help resolve the concerns. When the culture of safety is strong, people report concerns without fears of retaliation. Employees respond supportively to concerns about risks to patient safety and do not seek to blame individuals when an error occurs. When safety is a priority, leaders routinely inquire about safety concerns and take the time to listen, seek to understand root causes, demonstrate their commitment to safety through action, and communicate back to staff on the organizational response to adverse events and concerns. An organization’s culture of safety can be measured by the Agency for Healthcare Research’s survey on patient safety culture. The scores of this survey have been correlated with patient outcomes in multiple studies and can assist an organization with monitoring their culture over time. Specific questions may also be useful to assess the effect of culture on identifying problems (Table 19-2).