Patient Safety Culture Analysis

The Healthcare field is becoming more aware of how important it is to change the way that organizational culture is becoming in order to help improve patient safety. Even though patient safety plays a very important part of our health care system which helps explain the importance quality of health care. However, when trying to keep patients safe, it can be a demanding challenge because of human errors and mistakes that are made. According to World Health Organization, patient safety is the absence of preventable harm to a patient while in the process of health care (who.int/patientsafety). Being in the position of a clinical content manager, the first step in reporting problems is to make sure that when reporting a problem, it need to be done at the earliest stage to show the importance to the company. The approach that I would take as a Clinical content manager is to identify the problem, have regular shift meetings to address any issues, flag any errors that occurred, have regular safety meeting, give feedback to staff on any errors that were found, try to figure out the best solution not only for the patients, but staff also, and although being a team leader, I would give the staff the opportunity to address any concerns that they may have.

The risk management program in any business, especially in a health care organization is an integral part of its day to day operation. The purpose of the risk management department is summed up by Kavaler & Alexander (2014), “…a program designed to reduce the incidence of preventable accidents and injuries to minimize the financial loss to the institution should any accident or injury occur” (p. 5). Protecting employees, patients, vendors and visitors is an ongoing process and one that needs to be updated when the healthcare organization has deemed necessary. This paper will demonstrate the importance of presenting the risk management program to new employees, compliance with the standards set forth by the American Society of Healthcare Risk Management (ASHRM), propose recommendations or changes needed to further improve the program, as well as examine the administrative process of managing a risk program.

The healthcare setting should be a safe environment. By employing the four characteristics of a culture of safety an employer can maintain high employee satisfaction thereby improving retention. People are held responsible for their behavior in this culture but "a distinction is made between errors that result from poor decision making and those that result from system flaws." ("What are the," 2011) The four characteristics are psychological safety, active leadership, transparency and fairness.

As the Joint Commission aims to nationally improve health care systems through health care organizations collaborations, it publishes recommended patient safety goals. As stated by the Joint Commission, “the first obligation of health care is to “do no harm””. The Joint Commission’s 2015 National Patient Safety Goals for hospitals include : Identify patients correctly; Improve staff communication; Use

(2011). Teaching the Culture of Safety. American Nurses Association. Online Journal. Retrieved September 20, 2017.

Patient safety one of the driving forces of healthcare. Patient safety is defined as, “ the absence of preventable harm to a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the patient’s underlying disease process. (Kangasniemi, Vaismoradi, Jasper, &Turunen, 2013)”. It was just as important in the past as it is day. Our healthcare field continues to strive to make improvement toward safer care for patients across the country.

The Joint Commission has set forth standards for health care organizations to reduce the number of risks and amend the quality of care and the safety of the patient. Risk management and quality management focus on these attributes of the organization and the patient. Risks are impossible to avoid since it linked to everyday living and the workforce. Risk management must take the initiative to distinguish and oversee these risks. Due to the lack of consistency in the quality of care, health care organizations aim to reduce the negative outcomes of the patient safety through quality management methods. Internal and external factors may pose a risk that can have an impact on the organization and the consequence of the patient care and safety.

Throughout our healthcare career, continuous change is occurring in the healthcare industry. However, this change does not always mean that there is continuous improvement. As healthcare providers, we often do not see the near medication misses, or the sources of harm, we certainly do not see ourselves as a source of injury. So how can we solve the issues of thousands of patients dying or being harmed in equipped, highly trained hospitals? We need to look into high-reliability organizations safety models. We need to be sensitive to operations, reluctant to simplify, aware of catastrophes and predict them instead of reacting to them, ask for advice, and have strength. These characteristics can help to reduce patient safety concerns and potential

First is collective mindfulness. These means everyone within is expected to understand that issues may arise that can cause serious safety concerns. Safety is everyone’s responsibility as well as collective and shared responsibility (Ratwani, Hettinger and Fairbanks, 2014, p. 3). Second factor is dealing with reporting. There are processes in place that will report safety issues if one arises. The organization makes sure that the reports are easily accessible and useable as well as followed-up with. Lastly, is creating a culture that understands mistakes happen. Staff may not go around blaming others when something is interrupted, it is a team and events take place when humans are involved. This type of culture helps individuals know there are processes in place, provided by leadership to handle these type of serious safety events (Ratwani, Hettinger and Fairbanks, 2014). A major role to implement patient safety is by the use of health IT

In 2012, more than a decade after the IOM report inspired nationwide initiatives for remediation, medical errors were the third leading cause of death in the United States (Hospital Safety Score, 2013). Today, QSEN employs an enhanced approach and expanded outreach (Dolansky & Moore, 2013). The QSEN initiative shows promise, but to achieve measurable improvements in patient safety, health care organizations must also embrace a culture of safety.

In a perfect world, these defenses would be impenetrable and patients would always be safe.20-22 But that isn’t the case. These defenses, like slices of Swiss cheese, have holes—latent and active failures—that do not always prevent the human error from reaching the patient. Each piece of cheese (barrier) has holes, and when these holes line up, an error occurs. When defenses fail in health care, a patient or staff member is endangered or harmed. While leaders can and should support defenses and interventions to reduce risk, this is not enough; a culture of safety must also be established.30 In order to make progress in reducing harm and barriers to incident reporting, for further improving quality in healthcare, the most essential change needed is cultural, and in particular from a blame culture to a safety

There are a number of situations that arise in healthcare every day and each situation is handled differently. “Patient safety is one of the most prominent healthcare challenges worldwide”(Brasaite, 2015). For improving health care it is important to share the responsibility for patient safety between all caregivers. Patients are often unintentionally injured as a consequence of their treatment; therefore, it takes many people to help an organization run efficiently and effectively. It takes teamwork, collaboration, coordination, and communication. Moreover, “patients arrive in the healthcare system trusting that the system will not harm them, but this may not always be true” (Brasaite, 2015). Ensuring the highest quality of care possible to all patients requires understanding and adapting care to the patients’ unique needs and perspectives. Only then can high-quality care be achieved in a patient-centered manner.

The Patient Safety and Risk Management program will support Little Falls Hospitals philosophy; everyone is responsible for patient safety and risk management. It is essential to have participation and teamwork among providers, management, staff and volunteers. The Patient Safety and Risk Management program will be implemented with the coordination of multiple organizational and department functions and activities.

In 2008, the World Alliance for Patient Safety released a report of evidence on patient safety in which the positive characteristics of a patient safety culture were explained as open communication about safety problems, effective teamwork and support by local and organizational leaders who make safety a priority they also describe patient safety as global issue affecting all countries.(4)

Safety culture has taken on many varieties of definitions since the term first appeared in 1986 but a version I particularly identify with is as follows: “A set of values, perceptions, attitudes and patterns of behavior with regard to safety shared by members of the organization; as well as a set of policies, practices and procedures relating to the reduction of employee’s exposure to occupational risks, implemented at every level of the organization, and reflecting a high level of concern and commitment to the prevention of accidents and illnesses.” (Fernandez-Muniz et al., 2007, p. 628)