Beruflich Dokumente
Kultur Dokumente
Healthcare Safety
chrisry L. Beaudin, PhD LCSW CPHQ FNAHA
Luc R. Pelletier, MSN PMHCNS-BC CPHQ FNAHQ FAAN
Glenview,IL
Other titles in the Q So/utions Suite
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Copyright @ 2OI2 by the National Association for Healthcare Quality. All rights reserved.
Except as permitted under the United States Copyright Act of 1976, no part of this
publication may be reproduced or distributed in any form or by any means, including but
not limited to the process of scanning and digitization, or stored in a database or retrieval
system without the prior written permission of the publisher.
Copyright @ 2005, 2008, 2}12by the National Association for Healthcare Quality.
All rights reserved. First edition published in 2005. Second edition published in 2008.
rsBN 978-0-9858 336-2-6
Contents
l. StrategicConsiderations.,.. ..........,
A. TheHealthcareSafetylmperative.. ........... 1
SuggestedReading. .........37
Online Resources .....41
lndex. ........ 45
Vi Q SoluEions
Ta bles
Table 1. lOPatientSafetyFacts ...........4
Table 2. .
Patient Safety Culture Composites and Descriptions. ... . 10
Table 3. Safe PracticesforBetterHealthcare-2O10 Update ........12
Table 4. TheJointCommissionizotz HospitalNPSGs. ...........18
Gble s. lnformation Technology Commonly Used by Healthcare Professionals. ... . 22
Table 6. PotentialBenefitsandSafetyConcernsofHealthlTComponents.... ....22
Table 7. NQF, Consensus Standards Related to Disclosure of Error or lnjury. ..... . 2s
Table 8. NQF:SafePracticesRelatedtoMedicationAdministration..... .........26
Table 9. NQF:SeriousReportableEventsinHealthcare-2Ot1Update..... ....... 27
Figures
Figure 1. NationalQualityStrategyAims and PriorityAreas.. ....... 5
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viii Q SoluEions
Preface
Healthcare is complex and at times confusing to customers. Delivery systems, health plans,
solo and group practitioners, employers, and government agencies seek ways to achieve the
Triple Aim-ensure quality of care for the individual, improve the health of the population,
and control costs. Developing, deploying, and sustaining appropriate quality strategies
pose challenges and opportunities for healthcare quality professionals. Thoughtful
strategies employ effective, efficient, and evidence-based approaches to measure, monitor,
and determine outcomes. Did the actions and interventions yield intended goals and
objectives for improved quality and performance excellence? The healthcare qualiry
professional must successfully navigate the system to demonstrate quality and safety. The
application of sound theoretical and methodological practices is imperative. Q Solutfons
covers the breadth and depth of critical areas for professional development and leadership,
including frameworks for quality management, the linking of science with practice, and
the translation of data into practical information that can be used and understood by any
customer, whether it is a practitioner, third-party payer, or consumer.
The development of the third edition of Q Solutions was informed by the most recent
Healthcare Quality Certification Commission's (HQCC's) practice analysis. The practice
analysis assesses the current functions and competencies for certified professionals in
healthcare quality. Organized under the HQCC detailed content outline, the following
modules were created:
. Leadership andManagement
. Quality and Performance Improyement
. Healthcare Safety
. InformationManagement
. Regulation, Accreditation, and Continuous Readiness.
These modules feature critical components of healthcare qualiry the science and art
of qualiry and performance management, and environmental considerations such as
healthcare reform. In addition, Q Solutions was developed using feedback from healthcare
quality professionals and academic and policy experrs in the field.
In our world of teeming technology, rapid innovation, and continuously expanding
science, we also rely on hope day in and day out. We hope that political agendas will reflect
the needs of patients, families, and other stakeholders; that resources will be available for
the work to be done; and that fear will not result in barriers to uncovering mistakes, flaws,
and failures. For healthcare quality to permeate the healthcare landscape, the cultures of
silence that still exist in institutions must be eradicated.
In addition to emerging technologies and techniques, the foundation of our work
involves the collaborative relationships we form and develop with various stakeholders.
Our work, after all, is relationship based. Mutual respect and accord lead to mutual
understanding and a sense of camaraderie as we face complex healthcare quality
challenges. This is accomplished in many ways including affiliations with professional
groups such as the National Association for Healthcare Quality (NAHO.
Q Solutions is targeted to audiences across the care continuum and provides critical
knowledge to develop and enhance essential leadership skills in healthcare quality. In
effect, these tools and techniques are universal to any healthcare setting. The basic
principles can be adapted to your organization. When we embarked on the third edition
journey, there was no question about who the right people were to make these publications
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happen. We were humbled by-the company we kept. Fortunately, these individuals made
time for what proved to be a fruitful endeavor. The product you hold in your hands would
not have been possible without the uirceasing efforts of our esteemed authors-Cathy E.
Duquette, PhD RN CPHQ NEA-BC; Robert Rosati, phD; susan v. white, phD RN cpHe
NEA-BC FNAHQ; and Diane S. Brown, PhD RN CPHQ FNAHQ FAAN. Their vision
for NAHQ is depicted on every page. We thank them all for their thoughts and ideas
throughout the development process. In addition, we appreciate the thorough content
examination by our external review panel members-James B. Conway, MS LFACHE;
Gerald N. Glandon, PhD; John Hansen, MD MpH; Bernard J. Horak, phD FACHE cpHe;
and Barbara G. Rebold, MS RN CPHQ. As always, we acknowledge the continuous support
of the NAHQ Board of Directors, which has resulted in the successful launch of the third
edition of Q Solutions.
The work of healthcare quality professionals is noble indeed. Armed with a set of
advanced skills and practical tools, we are a force that can be boundless. Our nobiliry comes
from the fact that we are truth seekers. We are consrantly challenged to tell a qualiry story
that is cogent, accurately depicts healthcare circumstances, and is understood by varying
audiences. To be able to tell the truth, we must demand that healthcare organizations
' provide resources necessary to conduct investigations and to maintain reporting
systems that use state-of-the-art information technologies;
' allow and support a solid infrastructure for continuous readiness, including health
information technology that supports the continuous quality improvement paradigm
and doesn't disappear after an accreditation survey or regulatory audit;
' ensure that all organizations are educated on the science of discovery (i.e., data,
methods, analysis, and application); and
' contribute to the growing body of healthcare quality science by sharing evidence-
based, outcomes-oriented quality techniques making a difference in the safery care,
and service embraced by forward-thinking, highly reliable organizations.
Our primary goal for this suite of Q Solutions modules is to provide NAHe members
and other quality and patient safety professionals with a product that is reliable, valid,
innovative, and timely. These updated modules reflect recent changes in national
healthcare safety as well as the transformation of healthcare as we know it. In the future,
NAHQ plans to supplement these modules with other relevant topics and learning
opportunities.
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Christy L. Beaudin, PhD LCSW CPHQ FNAHQ is national director of qualiry for AIDS
Healthcare Foundation in Los Angeles, CA. In her current role, Dr. Beaudin is responsible
for healthcare safety, accreditation, infection prevention and control, public reporting, and
education. At the executive level, she led healthcare safety efforts at Children's Hospital
Los Angeles, PacifiCare Behavioral Health, and Value Behavioral Health, and served as
vice president of research and development at Magellan Behavioral Health. Dr. Beaudin
supported hospitals and managed care organizations in preparing for and maintaining
state licensure and accreditation compliance including the National Committee for
Quality Assurance (NCQA), URAC, Accreditation Association for Ambulatory Health
Care (AAAHC), and The Joint Commission. Dr. Beaudin earned her doctorate in health
services from the UCLA School of Public Health, master's degree in social work from San
Diego State Universiry and bachelor's degree in criminal justice from California State
Universiry San Bernardino. Dr. Beaudin is adjunct faculty at the Universiry of Redlands
and participates in state- and national-level qualiry initiatives for NAHQ, SNP Alliance, and
the California HealthCare Foundation. She is widely published, serves on several editorial
boards and review panels, and is a national subject matter expert on healthcare qualiry
behavioral health, and managed care.
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Adjunct Lecturer, Harvard School of Public Health
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Healthcare Safety I
Facilitate assessment and ongoing development of the organization's healthcare safety culture.
1.
2. Link healthcare safety goals and activities with the organization s strategic goals.
3. lntegrate concepts and evidence-based practices with the organization! healthcare safety program.
+. ldentify applicablllty of external healthcare safety initiatives (e.g., regulatory accreditation, National Quality
Forum, World Health Organization IWHO]).
5. Determine mechanisms and tools to evaluate the success of healthcare safety activities and innovations.
6. Contribute to the development, revision, and enhancement of a written plan for a healthcare safety program.
7. Demonstrate technologys ability to enhance the healthcare safety program.
8. Perform, coordinate, and integrate enterprise risk management into the healthcare safety strategy.
l. StrategicConsiderations
A. The Healthcare Safety lmperative
Eliminating medical errors is an urgent imperative in the healthcare industry. Healthcare
safery encompasses all healthcare settings and includes the patient and staff experience
as well as the clinical, environmental, and services aspects of safety. Whether the focus is
on medications or surgery the goals are the same-to ensure patients are being treated in
an absolutely safe environment. The current era heralds strategies such as "zero defects"
(Porche, 2006), "pursuing perfection" (Kabcenell, Nolan, Martin, & Gill, 2010), and "trans-
forming healthcare" (The Joint Commission, 2011). Accreditation and regulatory agencies
such as The Joint Commission, the National Committee for Quality Assurance, and the
Centers for Medicare & Medicaid Services (CMS) are supporting the movement to reduce
errors. Proposed solutions to improving patient safety range from computerizing physician
order entry systems to having patients indicate on their bodies with markers the area upon
which to be operated. To increase patient safery healthcare organizations need to conduct
a thorough analysis of where and how patients are at risk for potential medical errors. Byers
and White (2004) suggested that approaching patient safety within an organization re-
quires a review in six key areas: structure, environment, equipment/technologies, process-
es, people, and leadership/culture.
Evaluating structure involves reviewing whether facilities are designed to promote
safery the right supplies are being ordered, and policies and procedures address safety
considerations. Environmental factors such as lighting temperature, noise levels, surfaces,
storage, and ergonomics need to be assessed. Reviewing equipment/technologies involves
examining labels, instructions, and safety features to be sure potential errors can be
avoided when using a technology. Processes can lead to errors. Assessment determines
whether redesign would improve safety by looking at factors such as complexiry inconsis-
tencies, time consffaints, and the amount of human intervention (i.e., lack of automation).
The effects of staff on patient safety are complex. For example, employee attitudes,
motivation, health (physical and psychological), education, training and cognitive function-
ing can influence the likelihood of a medical error. A healthy workplace supports safery.
Recently, the effect of healthcare professionals' disruptive behavior has been shown to
undermine a culture of patient safety (The Advisory Board, 2010). Further, an entire body
of research ("human factors" research) explores the ways in which humans interact with
machines and the potential for deadly accidents. The leadership and culture of an organiza-
tion can drive safety when there is a willingness to allocate appropriate resources (e.g., staff
equipment), analyze processes, implement changes, support nonpunitive error-reporting,
and promote evidence-based practice.
2 Q SoluEions
Any improvement efforts focused on eliminating errors requires a just culture, detailed
analysis of the care delivery process, human factors that influence processes of care, and
the resources to bring about sustained systematic change.
1. Types of Patient Safety and Harm
The Institute of Medicine (IOM) report, To Err Is Ifumon: Building a Safer Heakh System
(IOM, Committee on Qualiry of Health Care in America [CQHCA], 2o0o), and its subse-
quent reports, caught the attention of providers, payers, and consumers by illustrating the
direct relationship between quality of care and patient outcomes. Further, Becher and Chas-
sin (2001) pointed out that patients can experience harm as the result of three types of
quality issues: underuse, overuse, and misuse of health services. Underuse occurs when pa-
tients do not receive beneficial health services (e.g.,5Oo/o of patients who have a heart attack
fail to receive beta blockers). Overuse occurs when patients undergo treatment or proce-
dures from which they do not benefit (e.g., 50% of X rays performed on patients with back
pain are unnecessary). Misuse occurs when patients receive appropriate medical services
provided poorly, adding to the risk for preventable complicarions.
Underuse, overuse, and misuse are considered \Maste and waste is costly. Berwick and
Hackbarth QOl2) believe that the best healthcare reform and cost reduction strategy is to
eliminate waste. They have identified six categories where considerable costs are repre-
sented by waste. Below is a list of categories and the estimated wasteful spending to the U.S.
healthcare system. Total waste detailed below cost the United States $558 billion-$1,263
billion in 2011.
1. Failures of care delivery: waste from poor execution or lack of best practice adoption
resulting in injuries and poor outcomes ($tOz billion-$15a billion)
2. Failures of care coordination: waste related to fragmented care resulting in complica-
tions, readmissions, declines in functional status, and increased dependency of the
chronically ill (925 billion-$a5 billion)
3. Overtreatment: waste from rendering care that is not useful ($tSS billion-$226 billion)
4. Administrative complexity: waste from state and federal government, accrediting agen-
cies, and payers creating inefficient or misguided rules ($tOZ billion-$389 billion)
5. Pricing failures: waste related to overpriced procedures and professional fees ($84
billion-$178 billion)
6. Fraud and abuse: waste from fraudsters and fake healthcare bills ($SZ bitlion-$272
billion (pp. E1-E2)
2. Transforming the Healthcare Delivery System Through National Policy
The IOM continued to highlight problems in healthcare delivery and reported, "The Ameri-
can healthcare delivery system is in need of fundamental change" (IOM, CQHCA, 2001, p. 1).
The report stated that healthcare frequently harms and routinely fails to deliver its potential
benefits. In addition, it concluded that care was not being provided with the best scientific
knowledge. The IOM report suggested an agenda for "crossing the chasm" by changing the
healthcare delivery system. Its agenda includes the following components:
. All healthcare constituencies (e.g., purchasers, healthcare professionals, regulators, con-
sumers) should commit to a national statement of purpose for the healthcare system,
setting six aims for improvement to raise the quality of care to unprecedented levels.
. Clinicians, patients, and healthcare organizations need to adopt a new set of principles
to guide the redesign of care processes.
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Healthcare Safety 3
. The government, through-the U.S. Department of Health and Human Senrices (HHS),
must identifi, a set of priorities to focus initial efforts, provide resources to stimulate
innovation, and initiate the change process.
' Healthcare organizations need to design and implement more effective support pro-
cesses to make change in the delivery of care possible.
' An environment needs to be created to foster and reward improvement in the context
of ever-expanding knowledge and rapid change. This is accomplished by creating an
infrastructure to support evidence-based practice, facilitating the use of information
technology, aligning payment incentives, and preparing the workforce to better pro-
vide care to patients.
As part of the agenda for change, the IOM proposed six improvement aims to address
key dimensions of healthcare qualiry. At a minimum, healthcare should be
. safe:Avoid injuries to patients from care that is intended to help them.
. effective: Provide care based on scientific knowledge regardingwho will likely benefit,
and restrain from providing care when it is not likely to benefit a patient.
o patient-centered: Care should be respectful and responsive to patient preferences,
needs, and values. Furthermore, patient values should guide all clinical decisions.
' timely: Wait times and harmful delays for those who receive and provide care should
be eliminated.
' fficient: Care should be provided in ways that avoid waste, including waste of equip-
ment, supplies, ideas, and energy.
' equito.ble: Care shouldnot vary in quality because of patients' personal characteristics
such as gender, ethnicity, geographic location, and socioeconomic status (IOM, CQHCA,
2001).
Organizations are challenged to maintain an infrastructure and dedicate enough
resources to continuously support these six aims and sustain high levels of performance
once desired levels of quality are achieved. A strong commitment to accelerated change is
needed and reflects focus, prioritization, alignment with mission and organizational goals,
and spread. These are evidenced by meaningful use of health information technology (IT),
developing effective multidisciplinary teams, and ensuring that the workforce is competent
to provide effective, safe care. Aligning reimbursement and incentives with quality also is a
critical component in meetingthe IOM's proposed aims.
The IoM has also defined the core competencies required for healthcare professionals
as they relate to quality and safety. These competencies include
. provide patient-centered care,
. work in interdisciplinary teams,
. employ evidence-based practice,
. apply quality improvement, and
' utilize informatics (IOM, Committee on the Health Professions Education Summit,
2OO3,pp. al-aQ.
Various health professions have taken the charge to ensure quality and safery are integrat-
ed into academic curricula. An example of this is Qualiry and Safety Education for Nurses
(QSEN), a formal program to guide faculty in providing this core content to furure health-
care frontline staff.
International health enterprises such as WHO blaze the trail for healthcare qual-
ity. Since 2002 WHO has addressed patient safery as a public health issue and designed
4 Q SoluEions
programs to address 10 facts about patient safety in the world. These facts are detailed in
Table l. The Patient Safety Curriculum Guide (wHO, 20tt) presents an interprofessional ap-
proach in educating healthcare professionals about healthcare safety.
Several national imperatives emerged in the first decade of the 21st century. In 20Io
Affordable Care Act legislation directed the HHS National Quality Strategy (NeS) "to better
meet the promise of providing all Americans with access to healthcare that is safe, effective,
and affordable" (National Priorities Partnership [NPP], 2OLl, p.2). The development of the
NQS would occur with input from various stakeholders to influence a realistic, achievable
strategy. As a result, the National Qualiry Forum (NQF) convened the multistakeholder Npp
comprising a8 public and private-sector partners to provide input as HHS developed the
NQS goals, measures, and strategic opportunities (Nppr 2OlL, p.2).
The Nctional Strategy for Quality Improvement in Health Care (HHS, 20I1b) describes
three broad aims of an NQS: better care, healthy people/healthy communities, and afford-
able care (i.e., The Triple Aim). The report highlights six priority areas for an NeS, one of
which is to "make care safer." The goals include the following (Npp,201t):
' Improve patient, family, and caregiver experience of care related to qualiry safery and
access across settings.
Table 1. 1O Patient
1. Patient safety is a serious global public health issue. In recent years countries have increasingly recognized the
importance of improving patient safety. ln 2oo2 WHO Member States agreed on a World Health Assembly
resolution on patient safety.
2. Estimates show that in developed countries as many as one in 10 patients is harmed while receiving hospital care.
The harm can be caused by a range of errors or adverse events.
3. ln developing countries the probability of patients being harmed in hospitals is higher than in industrialized nations.
The risk of healthcare-associated infection in some developing countries is as much as 20 times higher than in
developed countries.
4. At any given time, 1.4 million people worldwide suffer from infections acquired in hospitals. Hand hygiene is the
most essential measure to reduce healthcare-associated infection and antimicrobial resistance.
5' At least 50% of medical equipment in developing countries is unusable or only partly usable. Often the
eguipment is not used due to lack of skills or commodities. As a resulE diagnostic procedures or treatments
cannot be performed. This leads to substandard or hazardous diagnosis or treatment that can pose a threat to the
safety of patients and may result in serious injury or death.
6. ln some countries the proportion of injections given with syringes or needles reused without sterilization is as high
asTo%. This exposes millions of people to infections. Each year, unsafe injections cause .l.3 million deaths, primari!
due to transmission of bloodborne pathogens such as hepatitis B virus, hepatitis C virus, and HIV
7. Surgery is one of the most complex health interventions to deliver. More dran loo million people require surgical
treatment every year for different medical reasons. Problems associated with surgical safety ln developed
countries account for half of the avoidable adverse events that result in death or disability.
8. The economic benefits of improving patient safety are compelling. Studies show that additional hospitalization,
litigation costs, infections acquired in hospitals, lost income, disabihty, and medical expenses have cost some
countries between U.S. $o billion and U.5. $29 billion a year.
lndustries with a percelved higher risk such as aviation and nuclear energy have a much better safety record than
healthcare. There is a one in 1,oo0,Ooo chance of a traveler being harmed while in an aircraft. ln comparison, there
is a one in 300 chance of a patient being harmed while receiving healthcare services.
'10.
Patients' experience and their health are at the heart of the patient safety movement. The World Alliance for
Patient Safety is working with 40 champions who have suffered as the result of a lack of patient safety measures to
help make healthcare safer worldwide.
From l0 Facts on Patient Safery by World Health Organization, 2012. Retrieved from, www.who.int/features/factfitedpatient--safety/patient-safety-
facs/en/indexl.html. Copyright zOtZ by WHO. Reprinted with permission.
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Healthcare Safety
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*eatthy Peonle,l
Healthy Communlfies Affordable Care
From Input to the Secretary of Health and Human Services on Priorities for the National
Quality Strategy 6y National Priorities p-r*6h,r*,
washington, DC Nationa/ Qu ality Forum. Copyright zott. Reprinted with permission.
a practic ing the profe s sio n-with honesty, integritSl and accountabiliry;
a maintaining the level of competency as outlined in the Standards of Practice for Health-
c ar e Q uality Profess iona Is ;
prioriry" (IOM, CQHCA,2001, p.67). The Institute for Healthcare Improvement (IHI) adds
the observation that when patients are harmed, the cause can be traced mostly to flaws in
the system of care (IHI,2008).
Among errors, 85%o rypically are the result of systems issues, and t5% are attributable to
human factors (Deming, 2000). According to fHI, 'The key to reliable, safe care does not lie
in exhorting individuals to be more careful and try harder. It lies in learning about causes of
error and designing systems to prevent human error whenever possible" (IHI, 2008, p. t9).
Those working in healthcare safety who are involved in identifying and acting on opportu-
nities to improve safety must give attention to planning, development, implementation, and
evaluation, as well as to continuous improvement
Since the IOM started delivering reports on healthcare safety in 2000, various national
organizations, state and federal agencies, accreditation organizations, and professional as-
sociations have focused on the identification of safe practices and strategies for organiza-
tional or system-wide implementation. In addition, many states have established coalitions
to promote patient safety (Comden & Rosenthal,2OO2).
Addressing the need to improve the safe delivery of healthcare, Congress passed The
Patient Safery and Quality Improvement Act of zOOS (Patient Safety Act; Agency for Health-
care Research and Quality [AHRQ], 2005). To implement the Patient Safety Act, HHS issued
the Patient Safety and Quality Improvement final rule (AHRQ, HHS, 2008). The Patient
Safety Act and the Patient Safety Rule authorizedthe creation of patient safety organizations
(PSOs) to improve qualiry and safety through the collection and analysis of data on patient
events (Cartwright-Smith, Rosenbaum, & Sochacki, 20U).
PSOs are organizations that share the goal of improving the quality and safety of
healthcare delivery. Organizations that are eligible to become PSOs include public or pri-
vate entities, profit or not-for-profit entities, provider entities such as hospital chains, and
other entities that establish special components to serve as PSOs. By providing both privi-
lege and confidentialiry PSOs create a secure environment in which clinicians and health-
care organizations can collect, aggregate, and analyze data, thereby improving qualiry by
identifying and reducing the risks and hazards associated with patient care.
Eight patient safety activities are carried out by, or on behalf of PSOs or healthcare
providers:
. efforts to improve patient safety and the quality of healthcare delivery;
. collection and analysis of patient safety work product (PSWP);
. development and dissemination of information regarding patient safety, such as rec-
ommendations, protocols, or information regarding best practices;
. use of PSWP for the purpose to encourage a culture of safety and provide feedback
and assistance to effectively minimize patient risk;
. maintenance of procedures to preserve confidentiality with respect to PSWP;
. provision of appropriate security measures with respect to PSWP;
. use of qualified staff; and
' activities related to the operation of a patient safety evaluation system and the provi-
sion of feedback to participants in a patient safety evaluation system (AHRQ, n.d.).
As of November 2009,27 states plus the District of Columbia had passed legislation or
regulation supporting adverse event reporting to a state agency. The new laws and regula-
tions were intended to raise accountability in healthcare organizations. Public reporting
also has the potential to improve healthcare safety through event analysis and by examin-
ing and disseminating lessons learned (National Academy for State Health Policy, 2011).
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the nation's healthcare system, AHRQ developed its patient safety culture assessment tools
for healthcare. The Hospital Survey on Patient Safety Culture: 2012 tJser Comparative Database
Report (AHRQ, 2OL2) meets that need. Based on data provided voluntarily by hospitals, the I
report provides an initial set of results that hospitals can use as benchmarks to establish a
culture of safety in comparison to similar hospitals or hospital units. i
In 2008 AHRQ released its first benchmarking report (AHRQ, 2008b, chapter 5) based
upon an analysis of data from 400 voluntary participating hospitals. The results represent-
ed another cry for healthcare organizations to focus on their healthcare safety practices.
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10 Q SoluUions
2. Feedback and communication about Staff are informed about errors that happen, given feedback about
error changes implemented, and discuss ways to prevent errors.
3. Frequency of events reported Mistakes of the following types are reported: (t) mistakes caught and
5. Management support for patient safety Hospital management provides a work climate that promotes patient
safety and shows that patient safety is a top priority.
6. Nonpunitive response to error Staff feel their mistakes and event reports are not held against them,
and that mistakes are not kept in their personnel file.
7. Organizational learning-continuous Mistakes have led to positive changes and changes are evaluated for
improvement effectiveness.
8. Overall perceptions of patient safety Procedures and systems can prevent errors, and there is a lack of
patient safety problems.
9. Staffing There are enough staff to handle the workload, and work hours are
appropriate to provide the best care for patients.
10. Supervisor/manager expectations and Supervisorsfmanagers consider staff suggestions for improving
actions promoting safety patient safety, praise staff for following patient safety procedures,
and do not overlook patient safety problems.
11. Teamwork across units Hospital units cooperate and coordinate with one another to provide
the best care for patients.
12. Teamwork within units Staff support each other, treat each other with respect, and work
together as a team.
undertook an update of the original set and endorsed pracrices with significantly expanded
specifications, supporting literature, and guidance for implementation. In 2009, the prac-
tices were updated to address pediatric imaging, organ donation, caringfor caregivers, glyce-
mic control, and falls prevention. In 2010, NQF added evidence to the existing practices, and
more direction was given to healthcare professionals for implementation and patient and
family engagement. The resulting 34 safe-care practices are detailed in Table B (NeF, 2010).
Attention to infection prevention and control is growing as part of the national effort
to achieve "zero" preventable hospital infections. Public reporting of infection rates is the
"new clinical mandate" (The Advisory Board Company, p. 3). The 'Journey to Zero" includes
innovative strategies to eradicate hospital-associated infections through a process of laying
the foundation (sizing the burden), crafting a multipronged stratery (establishing frontline
awareness and minimizing pathogen opportuniry), and ensuring sustainable success (pro-
moting long-term gains; The Advisory Board Company, 2008, pp. 18-19). Research shows
that employing nine best practices can reduce the burden of hospital-associated infections.
These practices include
. apresent-on-admissiontutorial,
. an infectionomics primer,
. a prioritization compass,
. a hand hygiene compliance assessment,
. ahigh-touch objectspotcheck,
. central line certification,
. a dedicated insertion team,
. a Foley validity check,
. clockworkantibioticadministration,
. automated data intelligence,
. an off-protocol physician pilot, and
' real-time accountabiliry enforcer (The Advisory Board Company, 2008, pp. 18-19).
The National Healthcare Safety Network (NHSN) also plays a leadership role in pro-
moting patient safety by providing a secure, Internet-based safety surveillance system. It
collects and reports on national and state-specific standardized infection ratios for select
healthcare-associated infections.
Recently introduced in safe practices is the concept of fair and just culture (Marx,
2OO7).In a fair and just culture, everyone throughout the organization is aware that medi-
cal errors are inevitable, but all errors and unintended events are reported, even when the
events may not cause patient injury. This culture can make the system safer. A just culture
recognizes that competent professionals make mistakes and acknowledges that even
competent professionals develop unhealthy norms (shortcuts or routine rule violations);
nevertheless, this culture has zero tolerance for reckless behavior. Three principles of a just
culture are described as follows:
l. A fair and just culture is not an effort to reduce personal accountability and discipline.
It is a way to emphasize the importance of learning from mistakes and near misses to
reduce errors in the future.
2. In a fair and just culture an individual is accountable to the system, and the greatest er-
ror is to not report a mistake, and thereby prevent the system and others from learning.
Policies that would discourage any healthcare provider from self-reporting errors are at
odds with the goals of a fair and just culture.
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12 Q SoluEions
iafePractice't, ': Leadership structures and systems must be established to ensure organization-
Leadership Structures
"I wide awareness of patient safety performance gaps, direct accountabllity of leaders
and Systems , for those gaps, and adequate investment in performance-improvement abilities,
and that actions are taken to g,nsure safe c;re of every patient served.
-rt-..'
Safe Practice 2: Healthcare organizations must measure their culture, provide feedback to the
Culture Measurement, leadership and staff and undertake interventions that will reduce patient safety
Feedback, and lntervention risk.
'rSafe Practice 3' Healthcare organizations must establish a proactive, systematic, organization-wide
Teamwork Training and approach to developing team-based care through teamwork training, skill building,
Skill Building and team-led performance-improvement interventions that reduce preventable
harm to patients.
Safe Practice 4: Healthcare organizations must systematically identify and mitigate patient
ldentification and safety risks and hazards with an integrated approach to continuously drive down
Mitigation of Risks and preventable patient harm.
Hazards
Safe Practice 5: Ask each patient or legal surrogate to "teach back," in his or her own words, key '
Informed Consent information about the proposed treatments or procedures for which he or she is
being asked to provide informed consent.
Safe Practice 6: Ensure that written documentation of the patients preferences for life-sustaining
Life-Sustaining Treatment treatments is prominently displayed in his or her chart.
Safe Practice 7: Following serious unanticipated outcomes, including those that are clearly caused
by systems failures, the patient and, as appropriate, the family should receive
timely, transparent, and clear communication concerning what is known about the
event.
Safe Practice B: Following serious unintentional harm resulting from systems failures and/or errors
Care of the Caregiver that resulted from human performance failures, the involved caregivers (cllnical
providers, staff and administrators) should receive timely and systematic care to
include: treatment that is just, respect, compassion, supportive medical care, and
the opportunity to fully partlcipate in event investigation and risk identification and
mitigation activities that will prevent future events.
Safe Practice lO: Ensure that nonnursing direct care staffing levels are adequate, that staff are
Direct Caregivers competent, and that they have had adequate orientation, training, and education
to perform their asslgned direct care duties.
continued
I
Y;'
I
Healthcare Safety 13
,.,rn"di.1T"
(triticaf.care cetified') . , :, .,, i,
Safe Practice 12: Ensure that care information is transmitted and appropriately documented in
Patient Care lnformation atimely manner and in a clearly understandable form to patients and all of the
patient's healthcare providers/professionals within and between care settings who
need that information to provide continued care.
Safe Practice 13: lncorporate within your organization a safe, effective communication strategy,
Order Read-Back and '' structures, and systems to include the following:
Abbreviations ' For verbal or telephone orders or for telephonic reporting of critical test results,
verify the complete order or test result by having the person who is receiving
the information record and "read back" the complete order or test result.
' Standardize a list of "do not use" abbreviations, acronyms, symbols, and dose
designations that cannot be used throughout the organization.
Safe Practice 14: lmplement standardized policies, processes, and systems to ensure accurate
Labeling of Diagnostic labeling of radiographs, laboratory specimens, or other diagnostic studies so the
Studies right study is labeled for the right patient at the right time.
Safe Practice 15: A discharge plan must be prepared for each patient at the time of hospital
Discharge Systems discharge, and a concise discharge summary must be prepared for and relayed
to the clinical caregiver accepting responsibility for postdischarge care in a
timely manner. Organizations must ensure there is confirmation of receipt of the
discharge information by the independent licensed practitioner who will assume
responsibility for care after discharge.
Safe Practice 16: lmplement a computerized prescriber order entry system built upon the requisite
Safe Adoption of foundation of reengineered evidence-based care, an assurance of healthcare
Computerized Prescriber organization staff and independent practitioner readiness, and an integrated
Order Entry information technology infrastructure.
Safe Practice i7: The healthcare organization must develop, reconcile, and communicate an
lvledrcatron Keconcrlratron .accuratepatientmedicationlistthroughoutthecontinuumofcare
Safe Practice 18: Pharmacy leaders should have an active role on the administrative leadership
Pharmacist Leadership team that reflects their authority and accountability for medication management
Structures and Systems systems performance across the organization.
Safe Practice 19: Comply with current Centers for Disease Control and Prevention (CDC) hand
Hand Hygiene hygiene guidelines.
Safe Practice 20: Comply with current CDC recommendations for influenza vaccinations for
lnfluenza Prevention healthcare personnel and the annual recommendations of the CDC Advisory
Committee on lmmunization Practices for individual influenza prevention and
control.
Safe Practice 21: ,i.Gke actiqls tg prevent central line-Qssociated bloodstream infection by ,
Safe Practice 22: Take actions to prevent surgical-site infections by implementing evidence-based
Surgical-Site lnfection intervention praciices.
Prevention
continued
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Healthcare Safety 15
3. A new culture of patient safety is successfully created when all serve as safery advocates
regardless of their positions within an organization. Providers and consumers will feel
safe and supported when they report medical errors or near misses and voice concerns
about patient safety.
Healthcare organizations committed to a fair and just culture identify and correct the
systems or processes of care that contributed to the medical error or near miss; they do not
assign blame. When feeling protected by a nonpunitive culture of medical error reporting,
more healthcare professionals will report more errors and near misses, which will further
improve patient safety through opportunities for improvement and lessons learned (Cali-
fornia Patient Safery Action Coalition, 2008; Marx, 2OO7).
Senge's concept of the learning organization has been applied to heaithcare during the
past several years. His definition of a learning organization is one "where people continu-
ally expand their capacity to create the results they truly desire, where new and expansive
patterns of thinking are nurtured, where collective aspiration is set free, and where people
are continually learning to see the whole together" (Senge, 1990, p. 3). Alearninghealthcare
system "is designed to generate and apply the best evidence for the collaborative healthcare
choices of each patient and provider; to drive the process of discovery as a natural out-
growth of patient care; and to ensure innovation, qualiry, safery and value in health care"
(IOM, Roundtable on Evidence-Based Medicine [ROEBM], 2007, p.ix).The most pressing
needs for change identified by the IOM roundtable are those related to
. adaptation to the pace ofchange;
. strongersynchronyofefforts;
. culture of shared responsibility;
. new clinical research paradigm;
. clinical decision support systems;
. universal electronic health records;
. tools for database linkage, mining, and use;
. notion of clinical data as a public good;
. incentives aligned for practice-based evidence;
. public engagement;
. trusted scientific broker; and
. leadership (IOM, ROEBM, 2oo7,p. S).
Leaders must integrate healthcare safery practices as part of their organization's
strategic direction, and goals must be developed to ensure adoption and measurement of
safety practices. The patient safety program should be aligned with the mission, vision,
core values, and goals of the organization. National pressures mount, and new expecta-
tions emerge for leaders, including those of government agencies (e.g., CMS), public re-
porting groups (e.g., the Leapfrog Group and U.S. Ner.vs and World Report), accreditation
agencies (e.g., The Joint Commission and the Accreditation Council for Graduate Medical
Education), and third-pafty payers. Third-parry payers are just beginning the practice of
nonpayment for certain conditions that could have been reasonably prevented (e.g., pres-
sure ulcers) and serious preventable events (e.g., leaving a sponge in a patient during sur-
gery; see discussion of Nqf "never events," p.26). As consumers become more empowered
through consumer-directed healthcare, they will demand more from healthcare profes-
sionals and organizations.
16 Q SoluUions
As part of its duties, the governing body or board of directors holds responsibility to
promote quality of care and preserve safety. The heightened attention being given to
healthcare quality measurement and public reporting affects this responsibility. Quality
oversight is recognized more clearly as a core fiduciary duty relating not only to financial
health and reputation but to safety and quality of care. Ensuring and improving care cannot
be delegated to the medical staff and executive leadership. An activated board, in partner-
ship with executive leadership and medical staff, can set system-level expectations and ac-
countability for high performance, high reliabiliry, and the elimination of harm.
Qualiry and safety, which also can benefit financially stable and growing healthcare or-
ganizations, are of board interest and represent a fiduciary duty. Bond-rating agencies such
as Standard & Poor's and Moody's Investors Service stress the importance of healthcare
leaders' attention to clinical quality outcomes and safety as they make decisions about bond
ratings for hospitals. A recent Moody's publication noted,
Safety can be integrated into strategic planning. IHI QOOT) outlines six things all
boards should consider in their effort to improve quality and reduce harm.
1. Setting aims: Set a specific aim to reduce harm this year. Make an explicit public com-
mitment to measurable quality improvement (e.g., a reduction in unnecessary mortality
and harm), establishing a clear aim for the faciliry or system.
2. Getting data and hearing stories: Select and review progress toward safer care as the
first agenda item at every board meeting; progress should be grounded in transparency
and a desire to put a "human face" on harm data.
3. Establishing and monitoring system-level measures: Identifii a small group of
organization-wide measures of patient safety (e.g., facility-wide harm, risk-adjusted
mortaliry), update the measures continually, and make them transparent to the entire
organization and all of its customers.
Changingthe environment, policies, and culture: Committo establishingand maintain-
ing an environment that is respectful, fair, and just for all who experience pain and loss as
a result of avoidable harm and adverse outcomes (patients, their families, and the staff).
Learning, startingwith the board: Develop capability as a board. Learn how the best
boards work with executives and physician leaders to reduce harm. Set an expectation
for similar levels of education and training for all staff.
Establishing executive accountability: Oversee the effective execution of a plan to
achieve aims to reduce harm, including executive team accountabiliry for clear perfor-
mance improvement targets.
't'
Healthcare Safety 17
With the convergence of clinical care, safety priorities, and economic stabiliry, board
members'interestwill increase over time and create opportunities for healthcare quality pro-
fessionals to educate organizational leaders on the importance of paying attention to safety.
NPSG.ot.os.ol Make sure that the correct patient gets the correct blood when they get a blood transfusion.
NPSG.oz.os.Ot Get important test results to the right staff person on time.
Use medicines safely
NPSG.os.o+.ot Before a procedure, label medicines that are not labeled, for example, medicines in syringes,
cups, and basins. Do this in the area where medicines and supplies are set up.
NPSG.o:.os.oi Take extra care with patients who take medicines to thin their blood.
NPSG.oE.oo.ot Record and pass along correct information about a patients medicines. Find out what
medicines the patient is taking. Compare those medicines to new medicines given to the pa-
tient. Make sure the patient knows which medicines to take when they are at home. Tell the pa-
tient it is important to bring their up-to-date list of medicines every time they visit a doctor.
Prevent infection
NPSG.oz.ot.oi Use the hand cleaning guidelines from the CDC or the WHO. Set goals for improving
hand cleaning. Use the goals to improve hand cleaning.
NPSG.oz.o:.0l Use proven guidelines to prevent infections that are difflcult to treat.
NPSG.Oz.o+.ol Use proven guidelines to prevent infection of the blood from central lines.
N PSG.oz.oo.Ol Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.
UP.Ot.Ot.Ot Make sure that the correct surgery is done on the correct patient and at the correct place
on the patients body.
UP.ot.OZ.Ot Mark the correct place on the patient's body where the surgery is to be done.
UP.oi.o:.ot Pause before the surgery to make sure that a mistake is not being made.
From "2012 Hospital National Patient Safety Goals," by The Joint Commission, 2012. Retrieved from wwwjointcommission.orgfassetsftfdfzotz-
NPSG-HAP.pdf. Copyright zotz by The Joint Commission. Reprinted with permission.
Healthcare Safety 19
healthcare leaders have a dug to recognize the inevitability of human error, attempt
to design systems that make such error less likely, and avoid punitive reactions to honest
errors. Regardless of the setting or type of healthcare organi zation, the scope and oversight
of the patient safety program includes the following areas:
. governance and leadership,
. creation ofa culture ofsafety,
. creation of a learning environment,
. definition of objectives,
. design ofsafe processes,
. process implementation, and
. measurement, monitoring, and improvement.
The patient safety program provides a coordinated and integrated system for hospital-
wide assessment and improvement of interrelated safery support, and clinical care pro-
cesses that affect patient outcomes, including standards compliance. Healthcare qualiry
professionals can develop a patient safery program by
. using comparative data;
. working collaboratively to improve compliance with the Joint Commission NPSGs,
Leapfrog Safe Practices, NQF-endorsed measures, and federal government-vetted
measures (e.g., AHRQ, NHSN);
. assisting all services and programs across the continuum of care by identifying and
mitigating risks and hazards;
. working collaboratively to enhance the adverse event, sentinel event, and peer review
processes; and
. promoting transparency and dissemination of results across their organization.
An organization should determine which performance improvement methodolory
should be adopted and emphasize the improvement of systems and processes, retrospec-
tively and proactively. A learningwork environment can be created that is just (nonpunitive
and accountable) and flexible, employing techniques such as root cause analysis, healthcare
failure mode and effects analysis, proactive risk assessment, evidence-based healthcare
methods, and the monitoring of measurements over time. An organization also can look
to build the skills of those working on improving patient safery such as avowing common
pitfalls when conducting a root cause analysis (ISMP, 20U).
Safety oversight should be provided by an organization's governing body, leadership,
and medical staff. Patients and their families should be involved in quality and performance
improvement activities, as appropriate.
B. Health lnformation Technology
Health IT holds the promise of making healthcare services safer and offers alternatives for
clinical decision support. If health IT is to work, the healthcare consumer must be at the
center of the healthcare system and be empowered to own his or her personal healthcare
data. If IT is to be effective in the care setting, it needs to be integrated with the patient
and clinical workflow and aligned with available resources and the expectations of the
end users. Some say not enough evidence exists to support the link benveen electronic
health records (EHRs) and patient safety (Parente & McCullough, zoog). The following
are questions for consideration: Is health IT easy to use? How quickly does it process
information? How functional is it? Health IT and interoperable systems are requisites
for healthcare delivery in the 21st century. Health IT potentially includes products such
20 Q SoluEions
as EHRs; patient engagement tools such as personal health records and secure, private
Internet ptrtals; and health information exchanges. A recent IOM report (IOM, 2Ol2)
that examined the state of the art in system safety and opportunities to build safer systems
concluded that
. Safety is an emergent property of a larger system that takes into account not
just the
software but also how it is used by clinicians.
. The'sociotechnical system" includes technology (software, hardware), people
(clinicians, patients), processes (workflow), organization (capacity, decisions about
how health IT is applied, incentives), and the external environment (regulations,
public opinion).
. Safer implementation and use of health IT is a complex, dynamic process that
requires a shared responsibility between vendors and healthcare organizations.
. poor user-interface design, poor workflow, and complex data interfaces threaten
patient safety.
. A lack of system interoperability is a barrier to improving clinical decisions and
patient safety.
. A constant, ongoing commitment to safety-from acquisition to implementation and
maintenan..-ir needed to achieve safer, more effective care (IOM,2OL2,pp. S2-Sa).
The HHS Office of the National Coordinator (ONC) was charged with developing
a Nationwide Health Information Network (NHIN) to 'provide a secure, nationwide,
interoperable health information infrastructure that will connect providers, consumers,
and others involved in supporting health and healthcare" (HHS, ONC, 2008). The NHIN's
purpose is to allow health information to be accessible to healthcare providers regardless of
where patients are treated. NHIN will achieve this goal by
. developing capabilities for national standards-based, secure data exchange;
. improving the coordination of care information among hospitals, laboratories,
physician offices, pharmacies, and other providers;
. ensuring that appropriate information is available at the time and place of care;
. ensuring that consumer health information is secure and confidential;
. giving consumers new capabilities to manage and control their personal health records,
,r *.tt as providing access to their health information from EHRs and other sources;
. reducing risks from medical errors and supporting the delivery of appropriate,
evidence-based medical care;
. lowering healthcare costs resulting from inefficiencies, medical errors, and incomplete
patient information; and
o prorloting a more effective marketplace, more competition, and increased choice
ihrough accessibility to accurate information on healthcare costs, qualiry, and
outcomes (HHS, ONC, 2008).
An exemplar of this strategy is the implementation of a Virtual Lifetime Electronic
Record (VLER) by the U.S. Department of Veterans Affairs (VA). The VLER program
ensures that each veteran has an electronic health record that can be accessed,
with the
veterans permission, by public and private sector healthcare providers. The first
pilot of
this program occurred in-San Diego, CA, betrveen the VA, the U.S. Department of Defense,
and Kaiser Permanente.
Any health IT discussion needs to address privacy protection and confidentiality in the
NHIN. A study at a major medical center involved l0o patients from six disease groups:
Healthcare Safety 21
breast cancer, colon cancer, cystic fibrosis, diabetes, HIV infection, and sickle cell anemia.
When the patients were asked about privacy protections, they ranked the following topics as
needing the most protection: abortion history, mental health history HIV/AIDS, genetic test
results, drug and alcohol history, and sexually transmitted disease history (Plantinga et al.,
2003).
W. Edward Hammond presented solutions to the interoperability dilemma. He
proposed the following to meet the goals for a single EHk (1) a unique identifier is needed
for each person in America; (2) all stakeholders need to agree on a common terminology;
(3) all stakeholders need to use standardized data elements with a single terminolory;
(+) the leaders of all types of healthcare organizations (practitioners, group practices,
healthcare enterprises, and health plans) need to be totally committed to modernizing care
delivery through health IT; (5) a national leader is needed who can articulate what needs
to be done at a national level to meet these goals; (6) vendors need to be brought into the
process of modernizing the healthcare infrastructure; (7) a sustainable funding model must
be developed; and (8) a feasible timeline should be developed (Hammond, 2OO7). EHRs
have the potential to capture data that can be reported for purposes of healthcare safety
performance and improvement.
Leadership plays a critical role in the adoption of health IT. But major barriers
to realizing its potential benefit exist. These barriers include the need for increased
standardization, funding regulatory relief, a single set of privacy and security laws, and a
uniform approach in matching patients to their records (Merritt, 2OO7).
Various technological solutions have been proposed to enhance patient safety
programs. The premise of these solutions is that if processes are standardized and the
potential for medical error is reduced by the automation of processes, errors will be
mitigated. Clancy (2005) proposed four health IT goals: (1) connect health records, (z) build
smart systems, (3) put the patient at the center of care, and (+) put prevention at the center
of treatment. In healthcare, technology can be applied to the work of nurses and other
healthcare professionals. Table 5 illustrates this point.
EHRs typically include four core components: electronic clinical documentation,
results reporting and management, electronic prescribing, results reporting and
management, and clinical decision support. Barcoding and patient engagement tools
have been added. Table 6 provides potential benefits and safety concerns of health IT
components.
C. Risk Management
Enterprise risk management is recommended as a strucflrred analyical process focusing on
identifying and eliminating the portfolio of risks rather than risk avoidance (Carroll, zOOa).
The portfolio includes the domains of operations (the organization's systems and practices),
financial resources (the earning, raising, or accessing of capital and the costs associated
with transferring risk), human resources (recruitment, maintenance, and management of
the workforce), strategic direction (the organization's ability to grow and expand), legal and
regulatory affairs (compliance with licensure, regulations, and accreditation standards), and
technological resources (biomedical, health Il equipment, and devices).
Using an enterprise-wide approach can help healthcare organizations manage risk.
Organizations also should have established mechanisms for reviewing potential incidents
of risk and safety concern. All members of the workforce are responsible for identifying,
reporting, and documenting risk management and potential quality-of-care problems
that can influence patient safety. Effective strategies for proactively reducing errors and
Penulluo)
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Healthcare Safety 23
Bar coding
Bar coding can be used to track medications, orders, and other healthcare products. lt can also be used to verify
patient identification and dosage.
. identifu, evaluate, and prioritize areas of risk that affect the operations of the
organization;
. assess whether the identified risks are caused by internal (controllable) or external
(uncontrollable) factors;
. develop and propose comprehensive strategies to minimize risks;
. establish action plans to address problems when identified; and
. maintain a periodic evaluation of feedback to monitor the progress of strategies and
actions.
Healthcare qualiry professionals can also work with their organizations to design edu-
cational programs to help healthcare executives and other organizational leaders address
serious events when they occur, respond effectively and learn to improve safety as a result
(Conway, Federico, Stewart, & Campbell,20fD.
Disclosing errors to patients and families is becoming more common practice in
healthcare organizations across the country, especially in the aftermath of the Josie King
incident in Maryland. In 20Ol King was 18 months old when she died in a hospital as the
result of medical errors. NQF (2009) identified disclosure as an important part of error
discovery in contrast to tactics of the past, which sprang from fear and blame. A just culture
supports the disclosure of successes and failures. Healthcare quality professionals rypically
are involved in the handling of errors and work with quality management, enterprise risk
management, and legal professionals to determine a course of action. Table 7 outlines NQF
consensus standards regarding the disclosure of error or injury to consumers.
More recent literature on disclosure highlights the "respectful management" of adverse
events (Conway et al., 2011). The aims of this group's work were to
. encourage and help every organization to develop a clinical crisis management plan
before they need to use it;
o provide an approach to integrating this plan into the organizational culture of quality
and safery with a particular focus on patient- and family-centered care and fair and
just treatment for staff; and
o provide organizations with a concise, practical resource to inform their efforts when a
serious adverse event occurs in the absence of a clinical crisis management plan and/
or culture of quality and safety (Conway et al., 2Oll,p.4).
Organizations also should look for ways to encourage reporting using innovations such
as the "Good Catch Awards" at Johns Hopkins Medicine in Baltimore, MD. This reporting
system encourages every clinician to report situations in which patients are at risk and
potentially lifesaving actions are warranted. Actions reflected system change and were
evaluated for sustainabiliry such as the national recall of improperly labeled drugs that had
caused look- alike medication errors (McCook, 2 011).
leuoqol,Ua _
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26 Q SoluUions
A healthcare safety culture should have as its foundation an atmosphere devoid of blame,
and a search for opportunities for improvement should be employed. The organization should
have systematic ways to welcome the reporting of medication errors. Because 857o of errors are
the result of system failures and traditionally only Llo/o are due to human error, the exploration
of systems issues should be primary in identif,ring a root cause of error (Deming 2000).
NQF has endorsed, through a consensus process, the adoption of safe practices related
to medication administration (Table 8). Other organizations such as the Leapfrog Group
have supported their endorsement. More specific recommendations are found in Sofe
Practices for Better Heakhcare: 2O1O tJpdare (NeF, 2010).
lmplement a computerized prescriber order entry system built upon the requisite foundation of reengineered
evidence-based care, an assurance of healthcare organization staff and independent practitioner readiness, and
an integrated information technology infrastructure.
Standardize a list of "do not use" abbreviations, acronyms, symbols, and dose designations that cannot be used
throughout the organization.
The healthcare organization must develop, reconcile, and communicate an accurate medication list throughout
the continuum ofcare.
Pharmacists should actively participate in medication management systems by, at a minimum, working with oth-
er health professionals to select and maintain a formulary of medications chosen for safety and effectiveness, be-
ing available for consultation with prescribers on medication ordering, interpretation and review of medication
orders, preparation of medications, assurance of the safe storage and availability of medications, dispensing of
medications, and administration and monitoring of medications.
a
Standardize methods for the labeling and packaging of medications.
ldentify all high-alert drugs and establish policies and processes to minimize the risks associated with the use of
these drugs. At a minimum, such drugs should include intravenous adrenergic agonlsts and antagonists, chemo-
therapy agents, anticoagulants and antithrombotics, concentrated parenteral electrolytes, general anesthetics,
neuromuscular blockers, insulin and oral hypoglycemics, and opiates.
Healthcare organizations should dispense medications, including parenterals, in unit-dose, or, when appropriate,
in unit-of-use form, whenever possible.
Adapted from Safe Practices for Better Healthcare-2010 Update: A Consensus Report (abndged version), by National Quality Forum,2otO.
Copyright 2OlO by Natrbna/ Quaity Fo rum. Repinted with permission.
E. NQF'Never Events"
In 2008 CMS announced a proposed rule that would update payment policies and rates
under the hospital inpatient prospective payment system for fiscal year 2009, beginning
for discharges on or after October 1, 2008. The proposed rule included a discussion of
candidates for addition to the list of hospital-acquired infections for fiscal year 2009,
including several conditions that have been identified by NQF as "serious reportable
adverse events' (also called "never events'). The complete list of 29 serious reportable
events that was updated in 2011 is shown in Table 9 (NQF, 2OlLa, pp. iii-iv). CMS withholds
payment to hospitals if any of these events occurs in an acute care faciliry.
LZ Ireleg elecqtleoH ,
I
{.-.
28 Q SoluEions
misused narcotics. Sorrel Kinglater went public with her findings of breakdowns that led
to her daughter's death at Johns Hopkins Hospital, a premier medical system in Baltimore,
MD. The Josie King Foundation was established with the mission "to prevent others from
dying or being harmed by medical errors" (Josie King Foundation, 2008). Together with
the hospital and provider groups, King also founded the Patient Safery Group in 2OO4,
which upholds the mission to 'encourage a culture of safety by providing tools that allow
healthcare organizations the ability to communicate, collaborate, improve, and share"
(The Patient Safety Group, 2008). The recent focus on safety also requires that clinicians
engage patienB in their care. Patients and their families need to understand their role
and responsibilities related to safery. Patient-centered communication has been shown to
improve clinical outcomes (Epstein & Street, 2oo7).Various public and private entities have
launched several initiatives to support consumer engagement. They are described below.
AHRQ: TalkingQuality. TalkingQualiry is a comprehensive resource and guide for organiza-
tions that produce and disseminate reports to consumers on the qualiry of care healthcare
organizations (e.g., hospitals, health plans, medical groups, nursing homes) and individu-
al physicians provide. Consumer report sponsors share a common mission to improve the
quality of care consumers receive. They also share a common challenge on how to convey
comparative information about healthcare quality in a way that achieves the following ob-
jectives:
. Consumers are motivated to use it.
. Consumers can understand it.
. Consumers can apply the information to their own healthcare choices.
TalkingQuality offers
. innovative ideas for communicating complex information on healthcare quality to
consumers,
. information on the latest research findings, and
. real-world examples to illustrate various approaches and concepts.
While TalkingQuality focuses on the challenges and process of consumer reporting
much of the guidance applies equally well to organizations producing reports on healthcare
quality to drive quality improvement and to inform other audiences, such as providers of
care, payers, employers, and other stakeholders (AHRQ, n.d).
AHRQ: Communication and Patient-Centered Care Toolkits. These toolkits contain re-
sources to enhance communication befween caregivers and patients.
. ImprovingHospital Discharge Through Medication Reconciliation and Education,
. Improving Medication Adherence,
. Improving Medication Safety in Clinics for Patients 55 and Older,
. ImprovingPatient Safety Through Enhanced Provider Communication,
. Multidisciplinary Training for Medication Reconciliation,
. ReducingDiscrepancies in Medication Orders and Histories at Handoffs,
. A Simulation-Based Safety Curriculum in a Children's Hospital ED,
. Testingthe Reengineered Hospital Discharge, and
. Using Military Simulation to Improve Rural Obstetric Safery
AHRQ: Consumers and Patients. AHRQ has developed exceptional tools geared toward
consumers and patients, providing "the latest evidence-based information for improving
your health." 'Getting Safer Care" includes resources in various forms, including written lit-
erature, podcasts, and videos.
l Healthcare Safety
Americans for Quality Health Care Quality Tool Box Consumer Engagement. The Na-
29
tional Partnership for women and Families (NPWF) believe that "no rir4. person, group
or profession can improve health and healthcare throughout a communiry-wiihout the
sup-
port of others" (NpWF,2OL2).
The partnership has also developed a Consumer Partnership for e-Health. Tools have
been developed for engaging consumers.
Patient-Centered Outcomes Research Institute (PCORI). According to its website, pCO-
RI "is an independent organization created to help people rnake informed healthcare deci-
sions and improve healthcare delivery. PCORI will commission research that is guided
by
patients, caregivers, and the broader healthcare communiry and will produce
high integriry
evidence-based information. PCORI is committed to transparency rrrd rigorous stakeholi-
er-driven process that emphasizes patient engagement. PCORI will use" a variety of forums
and public comment periods to obtain public input throughout its work" (pCoRI, 20L2,
para.l-2).
In March 2012, the PCoRI Board refined its definition of patient-centered outcomes
research. "Patient-centered outcomes research (PCOR) helps people and their
caregivers
communicate and make informed healthcare decisions, allowing their voices to be heard
in assessing the value of healthcare options." This research answers patient-centered ques-
tions such as
1. Given my personal characteristics, conditions and preferences, what should I expect
will happen to me?
2. What are my options and what are the potential benefits and harms of those options?
3. what can I do to improve the outcomes that are most important to me?
4. How can clinicians and the care delivery systems they work in help me make the best
decisions about my health and healthcare? (PCORI, 2Ot2).
PCORI has established national priorities for patient-centered comparative clinical ef-
fectiveness, which are
' Assessment of Prevention, Diagnosis, and Treatment Options: the research goal is to de-
termine which option(s) work best for distinct populations with specific health problems;
' Improving Healthcare Systems: focuses on ways to improve healthcare services, such
as the coordination of care for patients with multiple chronic conditions;
' Communication and Dissemination: looks at ways to provide information to patients
so that they, in turn, can make informed healthcare decisions with clinicians;
' Addressing Disparities: ensures that research addresses the healthcare needs of all pa-
tient populations. This is needed as treatments may not work equally well for every-
one; and
' Accelerating Patient-Centered and Methodological Research: includes patients and
caregivers in the design of research that is quick, safe, and efficient (PCORI, 2OL2).
Partnership for Patients. Partnership for Patients: Better Care, Lower Costs is a new public-
private partnership that will help improve the qualiry safety, and affordabiliry of healthcare
for all Americans. Using as much as $I billion in new fundingprovided by the Affordable Care
Act and leveraging a number of ongoing programs, the U.S. Department of Health and Hu-
man Services (HHS) will work with a wide variety of public and private parrners to achieve
the two core goals of this partnership: keeping patients from getting injured or sicker in the
healthcare system and helping patients heal without complication by improving transitions
from acute-care hospitals to other care settings, such as home or a skilled nursing facility. Its
mission is to help patients "take care into their own hands."
-'1
30 Q SoluEions
Beyond reducing harm caussd in hospitals, the Partnership for Patients is an important
test of what can occur when the nation acts as one to address a major national health problem.
The recently formed Innovation Center at the Center for Medicare & Medicaid Services
intends to dedicate more than $500 million to test models of safer care delivery and promote
implementation of best practices in patient safety. CMS will also provide $500 million for
a community-based care transition program created by the Affordable Care Act to support
hospitals and community-based organizations in helping Medicare beneficiaries at high risk
for readmission to the hospital safely transition from the hospital to other care settings.
More than Z3OO partners, including more than 3,200 hospitals as well as physicians and
nurses groups, consumer groups, and employers, have pledged their commitment to the
Partnership for Patients (HHS, 2011, para. 1-4).
The Joint Commission empowers consumers by providing educational materials and
tools as navigational aids for complex healthcare systems.In 2OO2 in response to a public
outcry regarding unsafe practices, the Joint Commission, in collaboration with CMS,
launched a national campaign to urge consumers to take an active role in identifying
and preventing healthcare errors. The goal of the initiative was to empower consumers
to become active, involved, and informed participants on the healthcare team (Joint
Commission,2OI2b). The "Speak Up" initiative encourages consumers to
Speok up if youhave questions or concerns, and if you don't understand, askagain. It's
your body and you have a right to know.
Educate yourself about your diognosis, the medical tests you are undergoing and your
treatmentplan.
Know what medicctions you take and why you take them. Medication errors dre the
mo st co mmo n he akhcar e mistake s.
Use a hospital, clinic, surgery center, or other type of heakhcare organization that has
undergone a rigorous on-site evaluation against established state-of-the-art quality
and safety standords, such as those proildedby The Joint Commission.
Participate in all decisions about your treatment. You are the center of the healthcare
team. (The Joint Commission, 2012b)
Roizen and Oz, in their book You the Smart Patient: An Insider's Handbookfor Getting the
BestTreatment Q,oo6), provide consumers with "everything from selecting the best physician
or hospital to avoiding all manner of therapeutic misadventures" (Soo Hoo, 2006 ,p.4).
. It must be possible and delirable for everyone to follow a red rule every time in a pro-
cess under all circumstances (red rules should not contain verbiage such as "except
when . . ." or "each breach will be assessed for appropriateness).
. Anyone who notices that the red rule has been breached has the authority and re-
sponsibility to stop further progress of patient care associated with the red rule while
protecting the patient or employee from harm.
. Managers and other leaders (including the board of trustees) always support the work
stoppage and immediately begin rectifying the problem and addressing the underlying
reason for breaking the rule.
. The people who breached the red rule are given an opportunity to support their be-
havioral choices and are then judged fairly based on the reasons for breaking the
rule, regardless of rank and experience.
. The red rules are few well understood, and memorable (para. 7).
Healthcare scenarios for which red rules can be beneficial include patient identification
(using rwo identifiers before administering tests of any kind), sponge-count reconciliation,
time-outs before an invasive procedure, timely alarm response, and correct labeling of
specimens.
lV. Summary
This module includes a synthesis of current knowledge related to preventing errors and
reducing harm. Both strategic and operational components of developing a healthcare
safety program are presented. Beginning with the importance of leadership, the authors
discuss integrating healthcare safety concepts into an organization's vision, mission, strate-
gic plan, goals, and objectives. Healthcare safery goals from various organizations are also
presented as well as national and global imperatives to reduce harm in healthcare. Finally,
the authors provide guidance in using performance-improvement tools to integrate safety
into enterprise's operations. Comprehensive references, resources, and suggested readings
from the Journalfor Heakhcare Quality also are provided.
In summary, consensus and the scientific literature support the following healthcare
safety tenets:
. Healthcare leaders must set the vision, mission, purpose, and direction and adopt
healthcare safety practices proven to prevent error.
. Organizations should strive to create and maintain a fair and just culture emphasizing
learning from errors and near misses to reduce future errors. Instituting safe practices
decreases errors in healthcare.
. Error prevention and reduction of harm are the job of everyone, including consumers.
Empowering and engaging patients leads to better outcomes and fewer errors.
. Healthcare organizations must continue to adopt new and emerging evidence-based
safery practices.
.Healthcare quality professionals possess unique experience and expertise to assist with
the advancement of safety practices in their organizations and the community at large.
Operational considerations for healthcare qualiry professionals include program devel-
opment; technology to support the program; enterprise risk management; implementation
of safe medication practices; monitoring of errors and never events; consumer empower-
ment and engagement; and the adoption, spread, and evaluation of evidence-based safety
innovations.