Preventing Never Events with a Culture of Safety (2 of 2)
Click Here to see the first part of this article.
We have been examining guiding principles of high-reliability organizations (HROs) and how they function to reduce errors in hospitals, including “never events”. Previously, we reviewed the principles of “preoccupation with failure” and “reluctance to simplify interpretation.” Now we will conclude by looking at the last three principles:
- Sensitivity to operation.
- Commitment to resilience.
- Deference to expertise.
Sensitivity to Operations
HROs carefully consider the potential negative consequences of a change in practice before implementation of that change. This is done through a process called “failure modes and effects analysis” (FMEA). Failure modes are the potential problems identified during the development phase of a change that are likely to affect end users. Effects analysis refers to the process of studying the various outcomes of the identified problems. Steps in the FMEA process include identifying what may go wrong, the likelihood of it actually happening, potential risks to the patient and to the organization, strategies to eliminate, reduce, or control those risks, and methods for determining whether the effectiveness of those strategies.
After this phase of analysis, HROs speedily test and refine ideas on a small scale. Factors such as the organization’s size, culture, and processes affect the rate of adoption of new practices. Change is more likely to be accepted by employees if it’s given both a trial period to see whether it works and an opportunity to make modifications before organization-wide implementation is provided. For example, to prevent catheter-acquired urinary tract infections, it is important to understand the culture of nursing practice in areas with high utilization of indwelling urinary catheters. Placing an indwelling catheter in a patient changes the workload of the nurse in terms of toileting and urine measurement. Consequently, before any changes are made to a routine practice in multiple areas, HROs must anticipate and plan for the potential unintended effects on the nursing workload, as well as on the medical staff, patients, and their families. Setting up a trial period for the proposed changes in one clinical area will assist in identifying and evaluating unintended consequences before implementing that change for all target areas.
Commitment to Resilience
HROs successfully handle multiple unexpected events. Their systems have various fail-safe measures and staff members receive training in how to manage safety problems. Many electronic medical records (EMRs) now alert staff to potential errors and can catch mistakes before they occur. However, even with secondary safety systems, many nurses are unable to prevent errors due to shortages in staffing and a poor skill mix (the ratio of RNs to LPNs or unlicensed assistive personnel). Research suggests that up to 28% of nursing care goes unfinished. This is especially troublesome because unmet nursing care needs are closely associated with hospital-acquired conditions, such as infections, falls, and medication errors. Research also suggests that fewer negative patient-related events occur as the percentage of Registered Nurses in a unit rises. HROs commit to resilience when they strive for safer staffing with the proper nursing skill mix.
Deference to Expertise
Most decisions in HROs are made at the point of care. Decisions usually come from the top down, but in urgent situations, authority is placed on the member with the most expertise regardless of rank. In healthcare, many negative events have occurred because someone knew something was wrong but either didn’t speak up out of fear or spoke up and got ignored. Intimidation through power occurs frequently and unequally between healthcare professionals and, over time, leads to the formation of unhealthy unit norms. Consequently, excessive use of power and authority negatively affects team communication, resulting in failure to detect and prevent errors.
Effectively preventing never events requires teamwork, effective communication, and an open, collaborative work environment. Nurses and their leaders need directly address problematic communication behaviors together so that those problems do not threaten patient safety and the performance of the unit, which contributes to the occurrence of never events.
