Patient Safety Awareness Week – Embracing the Right ‘Culture of Safety’

Patient Safety Awareness Week began on Sunday. Therefore, it is only appropriate to commemorate this week (and all following weeks) with awareness about safe patient care among healthcare professionals and the public.

Much too often, patient safety is overshadowed by other healthcare-related issues (and agendas), such as expanding insurance coverage in state and local markets, medical and insurance mergers and acquisitions, and the opioid crisis – to name just a few. Some issues can’t be appropriately addressed soon enough (e.g. opioid epidemic), while other agendas are more about obtaining growth through acquisitions, often in the guise that more ‘value’ will be created to benefit the patient and the public. In healthcare, it appears optics is an extremely important and powerful tool.

So why is it so hard to make healthcare safer? There are many reasons, but four primary culprits stand out above all others:

  1. Complexity of healthcare delivery system

  2. Flawed systems are not designed to optimize patient safety

  3. Ineffective communication contributes to patient harm

  4. Weak incentives to push improvement processes

We all know that healthcare is complex. Much of it is due to flawed systems that are laden with unclear and distorted regulations often resulting in unintentional consequences which adversely impact patient care. Additionally, poor organizational safety cultures and communication practices compound the previous two reasons for unsafe care.

Much of the patient safety problem stems from not having a ‘business case’ to do the right thing at the right time. Business models are dependent on incentives – strong incentives – that will steer behaviors to the desired goal(s). When it gets down to it, inadequate financial incentives stunt the necessary initiatives required to spark safer patient care. Come to think of it, this is also part of human nature.

Unfortunately, in healthcare, it appears to be less about ‘doing the right thing’ and more about having appropriate incentives that will create the ‘business case’ of providing safe care to patients. This mentality must change.

After publishing ‘Iowans’ Views on Medical Errors,’ I created a number of Fact Sheets that address some takeaway thoughts for patients, employers and healthcare providers. These printable documents are found in the right sidebar on this HHRI webpage. Given the importance of this week, I would like to briefly address one particular Fact Sheet, ‘8 Strategies for Hospitals and Clinics to Prevent Medical Errors.’

I clearly realize that healthcare administrators will likely scoff at my ‘attempt’ to help them reform themselves, after all, they have been doing this reformation work for years, if not decades. But it seems to me – and many national medical experts included – patient safety begins with having a legitimate culture of safety at each medical establishment. And, it begins in the boardroom on down to each department in the organization. From this embedded culture, all other safety strategies can successfully follow.

My strategies, in no particular order – follow ‘culture of safety:’

  1. Embrace a culture of safety

  2. Treat staff burnout as an organizational priority

  3. Adopt a structure to improve patient handoffs

  4. Develop and nurture a patient and family-led advisory council

  5. Be vigilant about reducing infections

  6. Work to avoid diagnostic errors

  7. To avoid medication errors, find opportunities to include pharmacists

  8. Electronic health records systems must be interoperable

In 2017, the American College of Healthcare Executives and the Institute for Healthcare Improvement/National Patient Safety Foundation published an excellent resource to address this critical strategy for delivering safe care: “Leading a Culture of Safety: A Blueprint for Success.”

Patients experience medical errors not because doctors and hospitals wish to do them harm. Rather, unsafe care occurs because the systems and cultures of medicine influence medical providers to make decisions that don’t produce the best clinical results. It’s really quite simple. What patients want and need – coordinated and compassionate care that is affordable and safe – must align with the ‘business case’ of those who are paid to deliver it.

A ‘culture of safety’ should not just be a slogan in advertisements, but rather, THE reason healthcare organizations exist.

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