Although perfect is an impossible standard, as members of the healthcare community, we can learn from events we have witnessed as well as those that have been shared by others. The most successful organizations cultivate a culture that encourages transparency and reporting. Transparency allows for factual reporting, not just of events but also of hazardous situations or near-miss events, where the reporter does not fear retaliation or blame, even if describing their own error or omission.
By aggregating de-identified data, it is possible to perceive trends or early warning signs that can lead to interventions and thus prevent or mitigate potential hazards. For example, early in the COVID-19 pandemic, data showed that more pressure injuries occurred in patients ventilated in a prone position and that they occurred in unusual locations, such as the face or anterior chest. By monitoring this trend, acknowledging operations sensitivities and deferring to the expertise of clinical staff, high reliability organizations (HROs) were able to change their approach, implementing interventions such as improved padding or frequent position changes.
It is crucial in any organization to learn from both events as well as interventions that successfully prevent future occurrences. This applies to clinical staff, executive leadership and the board of directors. In addition, learning from what went RIGHT is important (principle of Safety II). Often there is one area, shift or person that yields better results. This may be attributed to better processes or planning for what could go wrong (preoccupation with failure), thus naturally preventing an error from happening.
After information sharing and learning from an adverse event has occurred, robust process improvements can be implemented throughout the organization. However, caution must be taken to avoid a “one-size-fits-all” approach. The HRO habit of “reluctance to simplify” should be applied since what works for one situation may need to be altered for another scenario. But that, too, is an opportunity to learn and share insights.
The Hudson Safety Culture Maturity Model outlines how organizations can follow an evolutionary pathway from being unmindful (accepting that incidents always will happen) to generative, an organizational culture that is “genetically” wired to produce safety. (Figure 1)
Figure 1: Hudson Safety Culture Maturity Model
References:
- Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91(3):459-490. doi:10.1111/1468-0009.12023
- Culture of safety: an overview. Health Syst Risk Manage2019 Jun 14. https://www.ecri.org/components/HRC/Pages/RiskQual21.aspx