The Joint Commission is guiding health systems toward becoming high-reliability organizations (HRO), similar to oil and gas, naval aviation, and nuclear power industries. These industries perform with a remarkable degree of safety, despite working in dynamic and hazardous conditions.
This degree of safety performance is no accident. Two researchers studied HROs and found repeatable practices that helped ensure safety.1 These organizations function under 2 sociocultural conditions. Organization leaders profoundly respect all employees, and all employees want to learn and improve safety and operations. They also operationalize 2 logics: (1) anticipate mistakes because all systems are fallible and standardize work when feasible to prevent mistakes and (2) recover from mistakes, building resiliency into daily work.
HROs know they must manage error effectively, or they will spend all their time responding to errors. Thus, they create mindful organizing structures in which they constantly envision what could go wrong and design systems to defend against and recover from mishaps. Although this preoccupation with failure is a tenet of HRO, it is often overlooked in health care.
Health care workers often assume things will go right rather than wrong. This is understandable because clinicians choose health care to help people--to fulfill a sense of altruism. Such optimism that all is well poses significant risk to patient safety. To defend against risk, regulatory organizations such as The Joint Commission require that health care organizations conduct a proactive risk assessment at least every 18 months after a new or changing process.
Although well intended, an 18-month stretch for risk assessments is hardly a preoccupation with failure. Preoccupation with failure is a mindset, a way to mindfully organize work, applied by all staff every day on the job. Being mindful does not mean thinking longer or harder, it involves thinking about and seeing risks and behaving to improve safety. The same sense of altruism can move every level of a health care organization to practice this preoccupation with failure every day--make it a habit.2
FRONTLINE CLINICIANS
Clinicians can incorporate risk assessments into daily processes of care, such as patient rounds or care transitions. Ask the simple questions: How might this patient suffer harm and how can we defend against those risks? For example, a patient with swallowing difficulties may be at risk for aspiration and could be placed on aspiration precautions. When transferring care, whether to another unit or on discharge to a skilled nursing facility or home care, the sending care team can communicate their knowledge of the patient's risks to the receiving care team. By incorporating a risk assessment into the handoff, information can be shared between the sending and receiving care teams that will ensure all patient care needs are met.
In daily care, clinicians should approach tasks with a mindset to look for errors rather than assuming what is in front of them is correct. For example, when nurses conduct a high-risk intravenous medication double check, the second nurse should assume the first nurse made a mistake, hunt for it, and correct it, rather than assume the intravenous pump is working or programmed properly and the medication is right. By engaging in this mindset, clinicians can develop a preoccupation with failure.
Frontline caregivers can also perceive near misses as equally important in the scheme of event reporting. Look for system defects that could cause harm and report them before an adverse event occurs.
UNIT-LEVEL MANAGERS
Unit managers can conduct huddles or briefings one or more times during the day to discuss clinical or operational risks to patients. For example, a charge nurse and unit attending might discuss which patients they are most worried about, how they will manage the demand for beds, and what may happen in the evening when nurse staffing is reduced.
Managers can also ask frontline staff that thought-provoking question, how will the next patient be harmed, and use their responses to proactively identify and mitigate those risks. This question is asked in many units throughout our health system that use the comprehensive unit-based safety program.3 Finally, managers can encourage staff to report risky system conditions (those near misses) and fix the problems that predispose staff to make mistakes, demonstrating respect for employees and boosting trust, common attributes in HROs.
DEPARTMENT-LEVEL MANAGERS
Department managers can hold daily huddles with unit managers to proactively identify department-wide clinical or operational risks. They can also examine risks at monthly management meetings and prioritize the greatest risks.
Department managers can assess whether management decisions create latent safety risks, anticipating the ramifications of these changes and mitigating the risks. For example, a decision to divert nurse training efforts away from infection prevention to train on a new electronic medical record could lead to increased infection rates. If managers got into the habit of anticipating the risks from their decisions, they may mitigate both the direct downstream risks and indirect risks on others.
Department managers can also use the event reports from clinicians across their units to identify emerging trends and persistent system failures that require resources and solutions at a higher level of the organization.
HOSPITAL LEADERS
Hospital leaders can hold daily huddles with department managers to identify clinical or operational risks and prioritize the greatest risk for harm at the hospital level and develop interventions to reduce that risk. Managers can also anticipate risks from their budget and operations decisions. For example, a decision to close some surgery beds to alleviate financial pressures can cause downstream problems, such as extended wait periods in the recovery room on stretchers, increasing the risk for pressure ulcers and patient dissatisfaction. Hospital leaders can also monitor and analyze event trends and support department managers' work, creating an enabling structure for safety.
FORMAL TRAINING AND PRACTICE
It is difficult for clinicians to develop these mindsets while on the job. Thus, these concepts could be introduced in medical school curriculum and reinforced by clinical educators during clinical rotations. University faculty could teach these concepts in the classroom and have students practice them in simulation laboratories, thereby embedding good habits rather than attempting to undo bad ones after a patient is harmed. For example, in a simulation laboratory, students or physicians could identify errors with a medication pump or a ventilator set up.
In conclusion, health care should evolve from randomly auditing potential risks for regulatory purposes to engaging staff in being preoccupied with failure and how to make patients safe every day. By using these habits, health care organizations might continue on their journey toward mindful organizing and becoming highly reliable.
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