Implementing Just Culture to Improve Patient Safety.

INTRODUCTION: The number of deaths in the United States related to medical errors remains unacceptably high. Further complicating this situation is the problem of underreporting due to the fear of the consequences. In fact, the most commonly reported cause of underreporting worldwide is the fear of the negative consequences associated with reporting. As health care organizations along the journey to high-reliability strive to improve patient safety, a concerted effort needs to be focused on changing how medical errors are addressed. A paradigm shift is needed from immediately assigning blame and punishing individuals to one that is trusting and just. Staff must trust that when errors occur, organizations will respond in a manner that is fair and appropriate. MATERIALS AND METHODS: An extensive review of the literature from 2017 until January 2022 was conducted for the most current evidence describing the principles and practices of "just culture" in health care organizations. Additionally, recommendations were sought on how health care organizations can go about implementing "just culture" principles. RESULTS: Twenty sources of evidence on "just culture' were retrieved and reviewed. The evidence was used to describe the concept and principles of "just culture" in health care organizations. Furthermore, five strategies for implementing "just culture" principles were identified. CONCLUSIONS: Improving patient safety requires that high-reliability organizations strive to ensure that the culture of the organization is trusting and just. In a trusting and just culture, adverse events are recognized as valuable opportunities to understand contributing factors and learn rather than immediately assign blame. Moving away from a blame culture is a paradigm shift for many health care organizations yet critically important for improving patient safety.

A High-Reliability Organization Framework for Health Care: A Multiyear Implementation Strategy and Associated Outcomes.

OBJECTIVES: Applying high-reliability organization (HRO) principles to health care is complex. No consensus exists as to an effective framework for HRO implementation or the direct impact of adoption. METHODS: The Veterans Health Administration (VHA) National Center for Patient Safety established the high-reliability hospital (HRH) model for HRO adoption and piloted HRH in collaboration with the Truman VA Medical Center (Truman) during a 3-year intervention period (January 1, 2016-December 31, 2018). High-reliability hospital components are as follows: annual patient safety (PS) assessment, annual PS culture survey, annual root cause analysis training, daily leadership walk-arounds, monthly PS forum, annual processes standardization review, Just Culture training, unit-based Clinical Team Training, unit-based continuous improvement projects, and annual Clinical Team Training simulation education. The impact of HRH was examined using a PS Culture Survey, PS event reporting, and quality outcomes of standardized mortality rate and complication rate. RESULTS: Truman internally improved PS culture and PS event reporting rates resulting in outcomes better than all VHA facilities (All VHA; P < 0.001 and P < 0.001, respectively). Low-harm PS event reporting increased (P < 0.001); however, serious safety event rate remained unchanged versus All VHA. Significant improvement in Truman standardized mortality rate and complication rate versus All VHA occurred immediately and were sustained through intervention (slopes, P < 0.001 and P < 0.020; respectively). CONCLUSIONS: High-reliability hospital is an effective framework for HRO implementation and will be applied to 18 additional VHA sites. Based on these results, the expected outcome will be improved PS culture and overall PS event reporting. The impact of HRH on serious safety event rate and quality measures requires further study.

Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem.

OBJECTIVES: The aims of this study were to investigate the demographics, causes, and contributing factors of retained guidewires (GWs) and to make specific recommendations for their prevention. METHODS: The Veterans Administration patient safety reporting system database for 2000-2016 was queried for cases of retained GWs (RGWs). Data extracted for each case included procedure location, provider experience, insertion site, urgency, time to discovery, root causes, and corrective actions taken. RESULTS: There were 101 evaluable cases of RGWs. Resident trainee (36%), critical care unit (38%), femoral vein (44%), and nonemergent placement (79%) were the conditions most frequently associated with a RGW. While discovery occurred almost immediately (30%) or in next 24 hours (31%), there were instances of RGWs found months (2%) or years (3%) later. Common root causes included inexperience (46%), lack of standardization (35%), distractions (25%), and lack of a checklist (23%). CONCLUSIONS: The results demonstrate the result of human factors-based errors such as posttask completion errors. We recommend human factor-based interventions such as checklists and devices employing forcing functions that do not allow clinicians to complete the insertion process without first removing the GW.

The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities.

Communication failure is a significant source of adverse events in health care and a leading root cause of sentinel events reported to the Joint Commission. The Veterans Health Administration National Center for Patient Safety established Clinical Team Training (CTT) as a comprehensive program to enhance patient safety and to improve communication and teamwork among health care professionals. CTT is based on techniques used in aviation's Crew Resource Management (CRM) training. The aviation industry has reached a significant safety record in large part related to the culture change generated by CRM and sustained by its recurrent implementation. This article focuses on the improvement of communication, teamwork, and patient safety by utilizing a standardized, CRM-based, interprofessional, immersive training in diverse clinical areas. The Teamwork and Safety Climate Questionnaire was used to evaluate safety climate before and after CTT. The scores for all of the 27 questions on the questionnaire showed an increase from baseline to 12 months, and 11 of those increases were statistically significant. A recurrent training is recommended to maintain the positive outcomes. CTT enhances patient safety and reduces risk of patient harm by improving teamwork and facilitating clear, concise, specific and timely communication among health care professionals.

Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork.

In healthcare, the sustained presence of hierarchy between team members has been cited as a common contributor to communication breakdowns. Hierarchy serves to accentuate either actual or perceived chains of command, which may result in team members failing to challenge decisions made by leaders, despite concerns about adverse patient outcomes. While other tools suggest improved communication, none focus specifically on communication skills for team followers, nor do they provide techniques to immediately challenge authority and escalate assertiveness at a given moment in real time. This article presents data that show one such strategy, called the Effective Followership Algorithm, offering statistically significant improvements in team communication across the professional continuum from students and residents to experienced clinicians.

A concept analysis of situational awareness in nursing.

AIM: This article reports an analysis of the concept of situational awareness in nursing. BACKGROUND: Situational awareness is a fundamental and well-understood concept used to maintain operational safety in high reliability organizations; however, it has not been studied in nursing. Nurses play a critical role in providing vigilance in health care and what they do or fail to do is directly related to patient outcomes. DATA SOURCES: Multiple databases, including PubMed, CINAHL, JSTOR, and Google Scholar, were searched with the term, 'situational awareness'. The primary search, used to identify all uses of the concept, did not employ date criteria. A secondary search for articles measuring situational awareness as an independent or dependent variable was completed using 2009-2011 articles. DESIGN: Concept Analysis. REVIEW METHODS: The concept of situational awareness was examined using Walker and Avant's eight step method of analysis. RESULTS: Three defining attributes of situational awareness include perception, comprehension, and projection. Situational awareness is defined as the perception of the elements in the environment in a volume of time and space, the comprehension of their meaning and the projection of their status in the near future. Although situational awareness is related to other terms in nursing, there is increasing recognition that the concept, which is likely a consolidation of the related terms, has an impact on healthcare professionals. CONCLUSION: Failures in perception, comprehension, and/or projection can significantly reduce the accuracy and appropriateness of patient care decisions. Therefore, as a precursor to decision making, poor or inadequate levels of situational awareness present serious threats to patient safety. Situational awareness needs to be examined in a theoretical context, studied systematically and openly recognized as a key factor in the delivery of safe patient care.

Nursing crew resource management: a follow-up report from the Veterans Health Administration.

In response to low scores on a patient safety culture survey, the Veterans Health Administration National Center for Patient Safety implemented a comprehensive nursing-focused crew resource management program for frontline nursing staff. This article highlights significant cultural and clinical outcomes from the program.

Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project.

AIM: To implement the sterile cockpit principle to decrease interruptions and distractions during high volume medication administration and reduce the number of medication errors. BACKGROUND: While some studies have described the importance of reducing interruptions as a tactic to reduce medication errors, work is needed to assess the impact on patient outcomes. METHODS: Data regarding the type and frequency of distractions were collected during the first 11 weeks of implementation. Medication error rates were tracked 1 year before and after 1 year implementation. RESULTS: Simple regression analysis showed a decrease in the mean number of distractions, (ß = -0.193, P = 0.02) over time. The medication error rate decreased by 42.78% (P = 0.04) after implementation of the sterile cockpit principle. CONCLUSIONS: The use of crew resource management techniques, including the sterile cockpit principle, applied to medication administration has a significant impact on patient safety. IMPLICATIONS FOR NURSING MANAGEMENT: Applying the sterile cockpit principle to inpatient medical units is a feasible approach to reduce the number of distractions during the administration of medication, thus, reducing the likelihood of medication error. 'Do Not Disturb' signs and vests are inexpensive, simple interventions that can be used as reminders to decrease distractions.

The case for training Veterans Administration frontline nurses in crew resource management.

Using cultural analysis, the authors present a rationale for a nursing-focused crew resource management (CRM) program in the Veterans Health Administration. Although the value of CRM in aviation is well documented and CRM has been successfully applied in healthcare settings to improve communication and teamwork, there is little evidence outlining the implementation of CRM on nursing units with nursing as the primary focus. This article describes the preproject data supporting a nursing-focused CRM program called nursing CRM. This is the first in a series of 2 articles highlighting this program.