Confession of errors is like a broom which sweeps away the dirt and leaves the surface brighter and clearer. I feel stronger for confession.
The definition of culture can be complex and wordy, but we can all recognize what it means. A
practical, easily understandable definition is - ‘the way we do things around here’. Leading five-
star hotels provide an excellent example of a great service culture. In the hospitality industry,
customers truly come first, whereas in hospitals, putting patients first is just a statement we pay
lip service to.
Design resilient systems
Along with inculcating a first class service culture, we also need to develop a culture of safety
in our hospitals. The problem is that today hospitals have a toxic culture of perfection, where
there is no margin for error. Because of the faulty way the system is designed, healthcare
professionals are trapped in a double bind. When nurses and doctors adhere to a norm that
says “hide errors,” they know they are violating another norm that says “reveal errors.”
Whichever norm they choose, they risk getting into trouble. If they hide the error, they can
be punished if the error is discovered. If they reveal the error, they run the risk of being
ostracized. The everydayness of errors means error hiding becomes a part of the culture of
Rather than continue fooling ourselves, we need to design error-proof and error-tolerant
systems in our hospitals - systems that are resilient and allow recovery from errors, rather
than brittle systems, which break down because of the burden of complexity and inefficiency.
In order to achieve perfection, we first need to acknowledge where we are imperfect, so we
can fix this.
A culture of safety is both proactive–built into the way the system is designed, so as to avoid
errors in the first place – and reactive – guiding the way we respond to errors when they do
occur. In pro-safety cultures:
*People willingly speak up when they see risky situations and behaviors
** Hierarchies are flat
* Workers follow critical safety rules
* The need for throughput is balanced against the need for safety
* Not only are people encouraged to work toward change, they are empowered to take
corrective action as needed
* Keeping quiet in the face of safety problems is taboo; the encouragement to be vocal
comes from all directions - from peers as well as leaders
The balancing act
Hospitals can improve upon safety only when the CEO and the management are committed
to change. The trouble is that safety does not generate revenue – in fact, it’s a drain on
resources. Also, while buying the latest MRI scanner is glamorous and exciting and can help
to attract patients, implementing safety measures is boring and mundane.
Sadly, safety is not the overriding priority in healthcare today. The reality is that safety has
to compete with a number of other organizational objectives, and since it’s less tangible and
less valued than a shiny new cardiac catheterization lab which rakes in the moolah, it is easily
marginalized and forgotten in the daily hurly burly of running a hospital .
Healthcare, just like every other industry, has to deal with the tension between safety and
throughput. In practice, a CEO needs to balance the need for patient safety along with
the hundred other tasks which compete for his attention daily, such as costs, profitability,
efficiency, access to care, and patient satisfaction. Similarly, a nurse in charge of a ward
juggles safety with the need for having to efficiently taking care of a large number of patients.
It’s tempting to cut corners and take shortcuts. Safety is constantly being balanced against
some other aspect of the quality of care, because of costs and resource limitations. In theory,
patient safety should always take priority over other objectives, but in real life, when there is
a clash between safety measures and other objectives, safety often becomes a casualty when
drawing up the budget.
Effective safety programs blend elements of top-down management and bottom-up
engagement and innovation. Management boards and physicians must be fully-engaged in
devising safety programs for them to be successful. When a hospital does not have such a
culture, staff members are often unwilling to report adverse events and unsa
because they fear reprisal or believe reporting won’t result in any change.
Hospitals and managers have to learn not to target people in the “name and blame” culture
that existed in the past. The philosophy should be “to err is human, to forgive divine”, so
everyone can learn from the error and then move on.
#1. Open culture- The staff feels comfortable discussing patient safety incidents and raising
safety issues with both colleagues and senior managers.
The five characteristics of a positive safety culture
#2. Just culture- This blends a systems focus with appropriate individual and institutional
accountability. This promotes both reporting of medical errors and professional accountability,
* Staff, patients and caregivers are confident that they will be treated fairly, with empathy
and consideration, when they have been involved in a patient safety incident , or have
raised a safety issue.
* A critical component of improving patient safety involves analyzing medical errors. We
need to learn from close calls, sometimes called “near misses,” that occur at a much higher
frequency than actual adverse events. Near misses are easier to learn from because there
is less guilt and secrecy associated with them. Since no one has been harmed, the staff is
much more willing to discuss these more openly, since there is no blame and no fear of
litigation. Addressing these not only results in safer systems, but also focuses everyone’s
efforts on continually identifying potential problems and fixing them. However, they will
not be reported if the team is bound by a “code of silence” or if individuals are fearful of
* Only those events that are judged to be an intentionally unsafe act can result in the
assignment of blame and punitive action. For example, intentional unsafe acts include a
doctor performing surgery when intoxicated.
#3. Reporting culture- Staff should have confidence in the local incident reporting system and
use it to notify managers of errors, including near misses:
* The reporting process should be easy
* The staff should not be punished for pointing out errors
* They need to receive constructive feedback promptly after submitting an incident report
* Reporting without learning serves no purpose and reporting systems need to include a
sense-making function, to make systems safer in the future
#4. Learning culture-The hospital is committed to learn safety lessons, which it communicates,
and remembers over time.
#5. Informed culture- The hospital has memory, because it learns from events that have already
happened (for example, through incident reports and investigations of sentinel events). It uses
this to identify and mitigate future incidents
Efforts that focus exclusively on eliminating errors will always fail. Individual errors will
always remain because of the role of fallible humans in delivering health care,; however, they
can be “trapped” or recognized before they reach the patient. The goal is to design systems
that are “fault tolerant,” so that when an individual error occurs, it does not result in harm
to a patient.
The personal qualities of the clinical staff play a key role in promoting patient safety. These
include: conscientiousness; humility and honesty; situation awareness; vigilance and open-
mindedness; anticipation and preparedness; team work and communication; and leadership.
It may seem to be a daunting list, but these are not new or mysterious skills -these are
essentially what the best healthcare professionals do in order to achieve consistently high
performance; and what the rest of us do on a good day.
Safety - the top priority
The Leapfrog Group has developed the Hospital Safety Score @ http://www. hospitalsafetyscore.
This grades hospitals in the US according to the safety measures they use. Process Measures
track how many patients receive the recommended treatment for a given medical condition.
For example, “Use antibiotics right before surgery” measures how often the hospital gives
patients an antibiotic within one hour before surgery to reduce postoperative infections.
Structural Measures represent the physical environment in which patients receive care For
example, “Doctors order medications through a computer” represents whether the hospital
uses a special computerized system to prevent medication errors. Outcome Measures checks
what happens to a patient while receiving care. For example, “Dangerous object left in
patient’s body” measures how many times a patient undergoing surgery had a dangerous
foreign object, like a sponge or an instrument, left behind in her body.
If we agree that the top priority in a hospital is safety and everyone is responsible for it, then we
need to ensure that the entire organization is wrapped around it, from the CEO onwards. Every
person caring for the patient has an impact on safety:
* For the surgeon, it’s making certain he adheres to specific processes, such as doing a time-
out before starting the operation
* For nurses, it’s double-checking what medications are being administered to a patient
* For the food-service worker, it’s verifying that the patient receives the correct diet
* For the environmental-service worker, it’s making sure the room is clean and uncluttered
to prevent infections and falls
The central question in safety is whether a junior staff member will have the courage to speak
up, not just when she’s sure something is wrong but, more important, when she’s not sure
that what the senior surgeon is doing is right. Safe organizations actively nurture a culture
in which the answer to that second question is always yes, and the CEO will compliment the
nurse for airing her concerns, even when it turns out that the surgeon was right. The role of
the CEO is to empower the front-line staff, and provide them with the resources they need,
so they can put patient safety first when doing their daily tasks.
Everyone has an important individual role, but we also have a collective role to promote
patient safety. The IHI (Institute for Healthcare Improvement) has some great ideas which
hospital CEOs can implement if they want to create a culture of safety. You can read these
at - http://www.ihi.org/resources/Pages/Changes/DevelopaCultureofSafety.aspx
Talk is cheap, and true commitment to patient safety requires action, not just statements. Since
an effective safety program depends on connecting the management (who control the budget
and set the priorities) with what is happening at the bedside, many hospitals have developed
strategies to connect senior leaders with caregivers. Senior managers can demonstrate their
commitment to safety by literally walking the talk! The communication should go two ways,
with both the executives and the medical staff talking honestly and listening carefully.
The session should be for about an hour every week, and the discussions should be focused
only on safety; don’t dilute the safety message by trying to cover other topics. The staff should
prioritize 2 to 3 items to be addressed. These sessions provide a very powerful message to
the hospital staff, about how seriously the hospital leadership takes patient safety. This is
the healthcare version of the time-honored business leadership strategy of “Managing by
Walking Around” (MBWA).
Story telling is a great way of communicating safety, and a simple play, with the staff as
actors, can reenact a real-life medical error or near-miss. This is a great way of raising safety
awareness, and can teach both staff and management valuable safety lessons. You can tell
one true story, or patch together real or plausible events. A commentary from the patient
safety officer or senior manager, or the people involved in the real event , can be a powerful
ending that reinforces the management’s safety culture.
Involve patients in safety initiatives
Patients and their families provide a very valuable layer of defense against adverse events,
and in fact they are often the best sources of information. Not only do patients and families
feel valued when they are involved in safety checks, they can help to unearth errors which
would otherwise have been overlooked, because they provide a fresh unbiased outsider’s
Staff members should always take patients and their families very seriously; and patients
should be encouraged to lead the hospital patient safety committee. There are some great
free tools which hospitals can use to can engage with patients called Patients as Partners at
A rapid response team
Hospitals need to set up a rapid response team, which can take prompt action in case a
complication occurs. This should consist of senior managers and experienced clinicians, who
can be mobilized instantly whenever there is an adverse event. They keep the atmosphere
in the unit calm; they mitigate harm to the patient; they curtail the blame game; they review
what happened; and they support the family, staff and physicians.
Not only does the medical team feel more confident with this kind of backup, the family is
also reassured when there are senior specialists who are actively engaged in the firefighting.
They are confident that the hospital is doing everything in its power to fix the problem. It’s
important to conduct drills to develop an organized response for actual events. Enough staff
members must be trained to have in-house response capability 24 hours a day, seven days a
week, along with a backup group of additional responders