While systems are designed to prevent harm to patients, their success hinges upon the willingness of staff to raise concerns when they sense concerns, said national safety expert Craig Clapper during the highlighted event of National Patient Safety Week at Christiana Care.
Clapper is a founder and the chief knowledge operator at Healthcare Performance Improvement, a firm that advises hospitals on safety practices. National Patient Safety Week, March 3-9, featured a number of education and awareness activities to celebrate Christiana Care’s commitment to prioritizing patient safety. This year’s theme was Patient Safety 7/365: seven days of recognition, 365 days of commitment to safe care.
Preventable errors will snake through the numerous walls of defense in a well-designed system when that system does not actively promote open and direct communication among its staff about concerns. When a culture of safety is absent, the well-designed system takes the form of a Swiss cheese model, Clapper said.
“Rarely is it a single thing that goes wrong that results in patient harm,” Clapper said. “In a Swiss cheese model, complex systems fail in complex ways. Systems of barriers are thought to be protective in this model, but really the model looks like slices of cheese, with the holes representing problems. What happens when one of those mistakes goes through the holes and reaches the patient? It causes harm.”
On the other hand, harm is prevented when human behavior is grounded in nontechnical skills such as situational awareness and critical thinking. Those skills will intersect with a health system’s safety initiatives, checklists and precautions, fortifying the safety bulwark of the health system so that errors never result in harm.
“What prevents harm more than anything else are the people and the culture within the health system,” Clapper said. “Because even when you have the right systems in place, there is still nearly always a discretionary space in which you are not forced to do something but still simply have to choose do it. For that reason, culture is the strongest behavior-shaping factor – it works in its own right plus it makes the other factors in a system work as well.”
For example, Clapper referenced a major culture shift toward safety in November 2003 at a multi-hospital system on the East Coast that triggered a continuous drop in the rate of serious safety events. The rate of serious safety events had dropped 81 percent over a seven-year period by August 2010.
Clapper said culture will begin changing when:
- New expectations are set.
- Staff are expected to consult their supervisers.
- Staff are expected to validate and verify what they know.
- Supervisers are expected to provide feedback to extinguish poor habits and build better habits.
“A culture should be designed so that instead of feeling that you are ‘allowed’ to speak up when you have a concern, you instead feel that it is an expectation in your health system that you speak up,” Clapper said.
Once that safety-first culture is the standard and behavior improves, it is incumbent upon a health system to continue to hone it to make it as safe as possible, Clapper said.
“Safety culture is the anecdote for work-around culture because whenever you force people to do something, they’ll look for workarounds if they don’t find value in it,” Clapper said. “But in a safety culture, no one looks for workarounds because they have prioritized safety. It restores the balance so you have people who realize it is important and they still want to do it.”
He added: “In a human-based system, what matters most is what we do. So anything that shapes behavior is strong at shaping outcomes.”