P A T I E N T S A F E T Y F I R S T

A .. Lreatinq a lust safety tult;re

linicians often talk about the culture of their hospital, OR, or ambulatory setting. What comprises that culture? Gener- ally speaking, culture is the

shared values, attitudes, and beliefs that exist within a specific organization. Recently, experts have suggested that health care organizations should create a culture of safety. Achieving this goal does not simply mean that clinicians need to be more careful and make fewer errors.

A JUST ENVIRONMENT Integral to establishing a culture of

safety is creating a just environment. Within such an environment, clinicians and other staff members are encour- aged, supported, and rewarded for pro- moting safety-related efforts and reporting errors.’ To create a just envi- ronment, the nature of medical errors must be understood and error report- ing valued. Clinicians and administra- tors must acknowledge that error-prone situations develop because of the com- plex nature of health care systems. There also must be a clear understand- ing that clinicians will make mistakes, and such errors occur as the result of underlying system failures.’

other staff members understand that they can discuss or report errors with- out fear of punishment or reprisal. Errors and near misses need to be reported and studied. Most nurses can recall a time when they discovered or were aware of an error but did not report it because they did not want to get a colleague in trouble. Traditionally, medical errors have been considered performance problems that can be addressed by counseling, retraining, re- educating, and restricting practice. Blame is placed on the clinician with-

In a just environment, clinicians and

out consideration of the factors con- tributing to the error.

FACTORS THAT LEAD TO ERRORS Most clinicians have been involved

in some type of medical error. Many nurses recall the first medication error in which they were involved. Typically, a nurse might comment, “I was so stu- pid,’’ ”I was careless” or “I didn’t fol- low the policy.” Rarely do nurses describe or discuss how system-related errors might have contributed to the error. For example, perioperative nurs- es might make an error when accessing an automated dispensing device for a medication. If different doses of the same medication are in the same draw- er, it might be easy to grab the wrong dose or strength. An error also could occur if a pharmacy staff member mis- filled the drawer or cassettes. Of course, nurses should verify the label on any vial or ampule. Labels, howev- er, may be difficult to read or mislead- ing and, thus, contribute to confusion. Medications also may have similar names or packaging, which can lead to misreading a label.

Errors involving medications, such as epinephrine, can and do occur. Epinephrine comes in multiple strengths and concentrations and often is dispensed in combination with other medications (eg, local anesthetics). Confusion can relate to the fact that epinephrine is labeled using its strength (eg, 1:1,OOO; 1:100,000) and not the milligram per volume convention used with other medications. These fac- tors can present a higher risk if a care- giver is rushed, tired, distracted, or under pressure during an urgent or emergent situation. Environmental and situational factors, such as poor light- ing, noise, or interruptions, can nega- tively influence clinician performance.

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FEBRUARY 2004, VOL 79, NO 2 Patient Safety First

All of these conditions con- tribute to errors at the "sharp end" where clinicians provide care and interact with patients.

A SYSTEMS APPROACH Rather than blaming staff

members involved in an error, health care facilities must examine how systems contributed to a specific error. Using a systems approach, facilities can enhance their reliability and, thus, reduce error potential. Decisions made by managers, equip- ment designers, architects, and others that contribute to error-producing or latent con- ditions at the "blunt end" of care processes can be identi- fied and addressed when sys- tems are examined.

The work environment can be redesigned to minimize factors that contribute to errors. Making it impossible for an error to occur by using forcing functions or making it difficult to make an error through the use of constrain- ing functions can help reduce errors at the sharp end of care. For example, a forcing func- tion exists when intravenous potassium is removed from floor stock and clinicians do not have access to it until a pharmacist has reviewed the order and dispensed the med- ication. An example of a con- straining factor involves the use of a device that does not allow a clinician access to a unit of blood before he or she has verified the blood unit number. When systems are designed to eliminate or

reduce errors, safety is enhanced. Some additional strategies that have been iden- tified as key to creating a cul- ture of safety include 0 simphfying tasks and

reducing hand-offs, 0 redesigning work processes, 0 reducing the need for

calculation,

A just culture should not be confused with one in which there is

no accountability. Clinicians must be

accountable f i r any deliberate actions that may result in

patient injury.

0 providing adequate

0 including human factor training,

design principles in clinical processes,

0 decreasing reliance on vigi- lance and memory, and

0 developing and enhancing data collection systems?

ACCOUNTABILITY As professionals, clinicians

often ask about accountabili- ty in a just environment. It could be argued that all errors are system errors. For example, if an organization

fails to provide safe equip- ment or adequate education and training, that could be considered a system-related problem. If a student learner graduates without adequate education and competence for safe practice, this also could be considered a sys- tem-related problem. The question, however, is should unsafe practice be blame-free and punishment free? The answer is no.

A just culture should not be confused with one in which there is no accountabil- ity. Clinicians must be accountable for any deliberate actions that may result in patient injury. For example, it is irresponsible for a nurse or physician to perform outside of their scope of practice. Clinicians who are reckless or choose to violate rules must be held accountable for these actions-if a clinician steals narcotics intended for a patient, that may constitute criminal negligence, especial- ly if the patient suffers from unrelieved pain. Clinicians also must be held accountable for their actions if they are reckless in providing care-if a clinician provides care after having consumed alcohol, that individual's practice should be considered reck- less. Such behavior would need to be addressed and managed appropriately.

CONCLUSION A blame-free, nonpunitive

culture encourages clinicians to report errors and truly learn from their mistakes. It

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also supports organizations in efforts to better understand their errors and make improvements. A just environ- ment assumes that clinicians at the sharp end of care are concerned about patient safe- ty but are working within complex systems and in situa- tions that potentially con- tribute to errors.

their own attitudes toward medical errors. Do they blame themselves or their col- leagues when errors actually occur? Do they think that errors primarily occur because of performance prob-

Clinicians need to examine

lems and not as a result of system failures?

in your clinical setting, and what do you contribute to that culture? Are you willing to report errors and to learn from those errors? Do you work with your colleagues to examine errors and idenhfy solutions to help prevent sub- sequent errors? Each clinician has a responsibility to work toward creating a just safety culture in their practice set- ting. Working together, we can reduce medical errors and adverse events while promoting patient safety. *:*

What type of culture exists

SUZANNE C. BEYEA RN, PHD, FAAN

DIRECTOR OF NURSING RESEARCH DARTMOUTH-HITCHCOCK MEDICAL CENTER

LEBANON, NH

NOTES 1. J Reason, "hgineering a safe

V t Ashgate Publishing, 1997). 2. L L Leape, "A systems analysis approach to medical error," in Medication Errors, ed M Cohen (Washington, DC: American Pharmaceutical Association,

3. M A Kadzielski, C Martin, "As- sessin medical error in health care. #evelo ing a 'culture of safe- ty,'" Health E!ogress 83 (Novem- ber/December 2002) 31-35.

culture," in Managing the Organizational Accidents

1999) 2.1-2.13.

Report Compares Health of US and European Teenagers eenagers i n the United States are more likely to T feel tired or "low" i n the morning than their

European counterparts, according t o an Oct 31, 2003, news release from the US Department of Health 8, Human Services' Health Resources and Services Administration (HRSA). A recent report released by HRSA compared the health and well- being of US and European teenagers. Data were taken from an international study titled "Health Behavior i n School-aged Children," which coordi- nated school-based surveys of children ages 11, 13, and 15 years i n US schools and in 29 locations throughout Europe in 1997 and 1998.

According to the report, Teens in Our World: Understanding the Health of US Youth in Comparison t o Youth in Other Countries, teens i n the United States were 0 more likely to have stomachaches, backaches,

headaches, and trouble sleeping "at least once a week";

0 less likely to smoke than students i n almost a l l other countries;

0 about as likely as teens i n other countries to drink alcohol "at least once a week"; and

0 among the most enthusiastic toward school, although approximately 80% reported liking school "only a little," "not very much," or "not at all."

Additionally, US students reported feeling safe at school "nevet" or "rarely." American students were i n the higher ranking of those who reported bullying other students frequently and ranked about average for being bullied by others "at least sometimes."

The report's authors contend that US students' fatigue may result from their high-fat, high-sugar diets and exercise levels i n the middle to lower range compared to youths i n other countries. The authors recommended conducting assessments of family stability, transient neighborhoods, and limit- ed community support among American families and developing programs for teenagers that deter bullying and other undesirable behaviors.

HRSA Report Compares Health of Teens in the US, Europe (news release, Rockville, Md: Health Resources and Sem'ces Administration, Oct 31, 2003) http://newsroom . hrsa.gov/releases/2003/teensurvey. htm (accessed 25 Nov 2003).

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