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Every organization needs a structure and a toolkit to support improving safety and quality. Since what cannot be seen cannot be fixed, robust identification of adverse events and sources of risk (risk to patients, to staff, and to the reputation of the organization) should be a priority of every hospital. This chapter begins with discussion of structures and tools to identify adverse events and risk-prone conditions. Once identified, the hospital and staff must then determine the priority items and which techniques will be applied to reducing adverse events and risks. Let us define a few terms for this chapter. Adverse events are instances of harm to patients resulting from medical care. Errors may be characterized as resulting from a flawed plan or from failure of a plan to be completed as intended. Not all adverse events result from error, and not all errors result in harm. A near miss is an error or system failure that is either intercepted before reaching the patient or causes no harm if it does reach the patient. Risk reduction efforts may focus on error prevention or on harm prevention. This chapter will not promote one approach over the other, as these principles and tools apply to both.

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Practice Point
  • Every organization needs a structure and a toolkit to support improving safety and quality. Since what cannot be seen cannot be fixed, robust identification of adverse events and sources of risk (risk to patients, to staff, and to the reputation of the organization) should be a priority of every hospital.

Where the culture of safety is healthy, it is easy to see that safety is a priority. People working in the area have a focus on safe practices and supporting one another in being safe and in delivering safe care. They may exhibit a “preoccupation with failure” as described by Weick and Sutcliffe, such that there is a general awareness of and attention to risks. Instead of ignoring small, nagging concerns, workers share those concerns with others, and team members rally to help resolve the concerns. When safety is a priority, physicians respond supportively to concerns about risks to patient safety and do not seek to blame when an error happens. When safety is a priority, staff supervisors and system leaders routinely inquire about safety concerns and take the time to listen, seek a deeper understanding of causes, and demonstrate their commitment to safety through action and by communication back to staff on the response to adverse events and concerns. Questions in Table 12-1 can be useful to assess the effect of culture on identifying problems. See Chapter 7 for a more thorough treatment of culture of safety.

Table 12-1 The Effect of Culture on Identifying Problems

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