“On our journey to zero harm, safety is the bedrock of everything. It’s critical to employee engagement, staff safety, and accessible, affordable, and quality care. Without a culture of safety, everything else crumbles, and we can’t ensure patient-centric outcomes,” Patty Harris said.
Pennsylvania Hospital’s Lisa McNamee, MSN, RN, a clinical nurse education specialist, and Joseph Gagnon, RN, knew something was wrong and that they needed to investigate. They had just received a heads-up from a lab scientist that a specimen sent from 4 Spruce had mismatched labeling; the medical record number (MRN) on the label did not match the MRN listed on the requisition. For safety reasons, the lab couldn’t process the sample, and the patient’s blood needed to be collected again – but how could a label printed directly from Penn Chart be wrong?
Rather than chalking it up to a fluke or ignoring the feedback altogether, McNamee and Gagnon dug deeper and contacted IS. Inter-departmental teamwork quickly led to the discovery of a mapping issue in Penn Chart that caused the PAH label to reflect the patient’s HUP MRN. Within 24 hours of the initial specimen collection, the problem was solved and no other patients experienced delays or required repeated needle sticks.
This was only one of the many recent “good catches” (189 in FY18 and 19 to date in FY19) that diligent staff have reported as part of their commitment to stopping adverse events in their tracks and maintaining a culture of safety at PAH.
A culture of safety is the foundation for all of PAH’s quality, safety, and patient experience efforts. Maintaining this foundation can be difficult when so many individuals are involved with a patient along their continuum of care, but it ultimately enhances patient outcomes, informs process improvements, lowers costs by preventing errors that could extend length of stay, encourages effective communication and collaboration between colleagues, and improves employee engagement.
The recent results of the Culture of Safety Survey indicate that since 2016, the “frequency of events reported” composite increased by 4.5 percent, and the “successful handoffs and transitions” composite improved by 2.4 percent. While these composites moved in the right direction, there were few significant changes overall. Multiple opportunities for improvement have been identified, such as improving our non-punitive response to error and performance management. These opportunities give PAH the ability to search for themes across departments and make improvements that are both unit-specific and span the hospital.
Just as each team developed individualized goals and action plans following the Engagement Survey, staff will be reviewing how their team’s strengths and areas for improvement compare to their colleagues across the health system and to national benchmarks. For Patty Harris, director of patient safety and process improvement, the hospital-wide goal is to build PAH into a high reliability organization (HRO) – an organization in which every staff member prioritizes safety and can anticipate potential problems, identify errors early, and respond to them before they escalate and harm a patient.
“An HRO requires three interconnected things: trust, reporting, and improvement,” Harris said. “Staff build trust in each other and with leadership and management by being honest about mistakes, taking action immediately after spotting a problem, and developing solutions collaboratively. Trust improves reporting, and consistent reporting prevents similar or more serious problems in the future. Those reports also create transparency at every level, which helps the frontline staff to trust leadership and management to respond to reports fairly and drive change. Leadership continues to foster trust by responding with curiosity as to why a reported error occurred and identifying opportunities for improvement.”
HROs also provide a solid foundation for a fair and just culture. Rather than blaming staff for system breakdowns or shaming them for human errors, fair and just culture promotes accountability and teachable moments. This ensures that every PAH team member understands their role in maintaining a culture of safety and feels safe and empowered to report issues. The complexity of health care may mean that errors are not completely avoidable, but by leveraging the results of the Culture of Safety Survey, keeping the goals of HROs in mind, and creating a fair and just environment, PAH can turn more potential problems into “good catches.”
“We’re in the midst of running a pilot program to determine how elements of a fair and just culture model can be integrated at PAH,” Harris said. “It all comes back to trust and to building an environment where patient safety is the primary concern, and no one feels as though they can’t or shouldn’t report a problem. We want to make it clear that we’ve heard staff and understand their concerns, and we’re committed to making it easy to do the right thing.”