1. Clements, Kimberly MSN, RN, CCRN, CNRN, NEA-BC

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Industries in which complex, high-risk work occurs and even a small mistake may have dire consequences develop processes to ensure an exceedingly consistent culture of safety. For this reason, we call them high-reliability organizations. Creating a culture of high reliability is crucial to get healthcare to the next level of patient safety.

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Principles 1 through 5

The five principles of highly reliable organizations-sensitivity to operations, being reluctant to simplify or normalize a problem or concern, a preoccupation with failure, deference to expertise, and resiliency-must be adopted by all members of the organization to be effective.1 These principles need to be second nature, hardwired into the organization for success. A collective state of mindfulness and mutual support elevates the organization to a true culture of safety.


Being sensitive to operations includes being transparent with data, paying attention to communication of positive and negative outcomes, and leadership rounding to influence positive results and encourage collaboration.


By not allowing a simple explanation to downplay issues or areas of potential harm, risk can be eliminated before it occurs. A questioning attitude is important when you need to drill down on processes and procedures that may not seem to exhibit an apparent defect, but have the potential to cause harm. Looking completely at the depths of defenses that are in place to prevent harm on an ongoing basis drives a continuous process improvement culture.


By being preoccupied with failure, we view everything through a questioning lens that asks, "What can go wrong here?" Employees are expected to question processes, actions, standards, and guidelines as opposed to settling for the status quo. The goal is to uncover a fault or defect before it comes to light through an event. This encourages staff members to report errors and near-misses, a practice that pushes process changes in an ever-improving and adapting environment.


When deferring to an expert, he or she isn't determined by position hierarchy or title; rather, the expert is most commonly the one who's closest to the sharp end of the process. Bringing frontline personnel into performance improvement initiatives identifies them as valuable subject matter experts who are crucial to discovering critical steps or anticipated failures. Their involvement eliminates others acting on assumptions instead of facts.


Finally, resiliency stops an organization from becoming paralyzed when a failure occurs, allowing for learning and growth. Being resilient means staying the course-even when faced with obstacles-to continue problem solving and swiftly find solutions to move toward success and improved safety.


Improving handoff

At Hackensack Meridian Health (HMH) in New Jersey, we're fostering a high-reliability culture within our 13-hospital system through implementation of standardized tools, such as checklists and safety monitors for all central line and urinary catheter insertions; promoting an atmosphere of nonpunitive early reporting of adverse events and near-misses; and encouraging transparency. In addition to these steps, we're currently working to improve handoffs during transitions of care by adopting I-PASS. Originating as a sign-out tool utilized by pediatric residents at Boston Children's Hospital to standardize the handoff process for their vulnerable patient population, I-PASS stands for illness severity, patient summary, action list, situational awareness, and synthesis by the receiver.2


Before implementing I-PASS, we used SBAR (situation, background, assessment, and recommendation). However, SBAR is an escalation tool, not a handoff tool. I-PASS possesses the specificity that a solid handoff requires. I-PASS offers a comprehensive look at the patient while highlighting areas that need to be communicated consistently across levels of care. The nurse or any member of the healthcare team can expect to receive the same information in the same order each and every time.


Illness severity defines the patient's current acuity. The patient summary is inclusive of, but not limited to, the patient's history and physical, test results, treatments, orders, and course of stay. The action list includes open items that require an action to complete, such as diagnostic tests, procedures, and consults. Situational awareness creates a plan in case the patient's condition deteriorates and identifies the immediate actions to address the change. And synthesis by the receiver is confirmation that the message sent is, in fact, the message received.


A team of nurse managers, clinical nurses, bedside ancillary staff, and nurse administrators took the I-PASS tool through multiple areas of HMH's Southern Ocean Medical Center's campus, including the critical care unit, postanesthesia care unit, medical-surgical unit, telemetry unit, and the ED, to create an inclusive, standard process to help decrease omitted information, miscommunication, inconsistent report formats, and personal bias. Small teams of nurses adapted the tool into a working document that was then deployed to the entire unit for a defined period of time.


After the teams obtained feedback, the tool was modified and then redeployed. This rapid cycle process was repeated multiple times and the tool was honed for several different areas. The I-PASS tool was then shared with two other campuses and their teams piloted it to account for different hospital cultures, patient populations, and environments.


Did it work?

Initial reception of I-PASS was mixed, particularly between novice and expert nurses. Experienced nurses who had their comfort zone and preferred format for report were resistant to the new I-PASS tool. The nurses who developed the tool were able to champion its use, receiving feedback from their peers and adjusting it to address expert nurses' needs, as well as environmental and patient needs.


In contrast, the novice nurses found security with the format. They appreciated the decreased variation and were enthusiastic to utilize a tool that was consistent from one nurse to another. Before I-PASS, the novice nurses were more reluctant to ask questions and clarify information with their seasoned colleagues. Instead, they would take time searching the chart or ask their peers for information after they had completed handoff. They found that the standard report prevented them from missing important information and having to ask too many questions. This also saved time because they trusted that the information they received was accurate.


For both groups of nurses, it was ultimately confirmed that I-PASS improved communication and decreased opportunities for error. The team reported back during informal inquiries and frequent meetings that the I-PASS tool better allowed them to be specific, standardized, and all-inclusive during report.


In addition, physicians reported during discussions at department meetings that they could tell the nurses were better informed and more knowledgeable about their patients during rounds, as well as being better prepared during emergent situations. The physicians were confident in and more trusting of the nurses and their communication. This shift in nurse-physician relationships created a more positive care environment for everyone involved.


Making healthcare safer

As a result of the team's hard work, I-PASS is now the standard communication tool used across all transitions and handoffs. Outcomes include increased staff satisfaction and, most important, reduction of errors. For example, through the I-PASS process, a chest tube that had been mistakenly clamped was discovered and addressed immediately. Another great catch was reported by a new nurse who questioned the appropriateness of a patient's I.V. fluids. She indicated that previously she and the off-going nurse may not have reviewed the fluids in such detail and she may have been leery to inquire or question her experienced colleague. The I-PASS tool gave her a concrete format to follow and confidence to clarify aspects of the patient's care. Although it's difficult to be 100% error-free utilizing a standard format for communicating patient information, such as I-PASS, is one more step toward becoming a highly reliable organization.




1. Weick K, Sutcliffe K. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco, CA: Jossey Bass; 2007. [Context Link]


2. Sectish TC, Starmer AJ, Landrigan CP, Spector ND;I-PASS Study Group. Establishing a multisite education and research project requires leadership, expertise, collaboration, and an important aim. Pediatrics. 2010;126(4):619-622. [Context Link]