As health care professionals, there are few things more agonizing than listening to a grief stricken mother describe how her young daughter, bravely fighting cancer, died during a hospital stay as a result of delays and failed communication. Looking at the audience at the Patient Safety Seminar that day, you could see that all of us felt her pain. After all, we got into the medical field to help people, to heal the sick and care for the most vulnerable, but in this case, we failed. Sadly, I have heard versions of that mom’s story many times throughout the years. The specifics change, but the result is the same -- the loss of life or permanent injury as the result of a medical error.
We aren’t perfect, I tell myself, as I hear those excruciating stories. We are human beings and sometimes, despite our best efforts, we come up short. But inevitably, as I let their brave messages sink in, I use those heartbreaking stories to motivate me -- to dig deeper and try harder and to become a more determined advocate for improving patient safety.
The American Nurses Associations (ANA) theme for National Nurses Week this year is Culture of Safety – It Starts with you
. Since the landmark Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System
was released in 1999, creating a culture of safety has been a major focus in our profession. The notion that medical errors resulting in patient harm are largely preventable and a result of system failures provided the platform for health care culture reform.
The IOM report provided clear recommendations to address medical errors. The government, professional organizations, and health care organizations have all worked towards reducing preventable medical errors. There is a plethora of information on culture of safety, including webinars, how to guides, frameworks, guidelines, etc. While we have made progress, preventable harm occurs in hospitals every day.
So what is a culture of safety? A culture of safety is an environment in which patient care is safe and effective, and patients are free from preventable harm. The complexity of systems in which health care is provided makes this challenging, but not
So, how can every nurse take a leadership role in creating and sustaining a high reliability culture of safety?
- Actively engage patients and their family as partners in care.
- Approach care delivery with interprofessional collaboration and teamwork.
- Promote a culture of blame-free reporting of adverse events and near misses; analyze and learn from them.
- Implement evidence-based best practices; remove barriers to ongoing sustainment.
- Maximize the use of technology as intended.
- Improve hand-off communication and transitions of care.
- Maintain a high level of situational awareness in your work area to anticipate problems ie., rounding, huddles.
- Speak-up if you witness or identify unsafe behavior or safety hazards and hold each other accountable to safe practices.
- Establish goals, measure outcomes and promote transparency of data.
During Nurses Week
this year, let us all make a commitment to ourselves, our teammates and those we care for, that we will become better patient advocates. Let us learn from those heartbreaking stories of loss and take whatever steps are needed to create and sustain an environment founded in a culture of safety -- every day and in every way.
Susan Mascioli MS, BSN, RN, NEA-BC, CPHQ, LSSBB
Director, Nursing Quality and Safety
Christiana Care Health System