Twenty years ago, when healthcare organizations investigated events that caused harm to patients, the focus was on individuals and their mistakes, rather than the integrity of the system within which people worked. Often called the “name and blame” culture, the emphasis in the wake of adverse events was not on learning and prevention, but rather individual correction via disciplinary measures.
In healthcare, like any other safety sensitive industry, we know that adverse events are more often the result of poorly designed systems that don’t interface well with humans creating the conditions for errors to occur. That’s why we’ve based VA’s patient safety program on a systems approach to analyzing error where the focus is on prevention, not punishment.
“Every day we focus on patient safety in VA,” according to Dr. Robin Hemphill, Director of VA’s National Center for Patient Safety (NCPS). “We especially recognize events held during Patient Safety Awareness Week (March 13-19), a week which brings focus to patient safety by the National Patient Safety Foundation.”
Training Sessions Mark Patient Safety Week
Next week, patient safety professionals across VA will sponsor events aimed at increasing awareness of patient safety at their facility.
To support programs that occur at local facilities, the VA National Center for Patient Safety is holding four training sessions. The VA has a systematic framework designed to improve patient safety. VA’s National Center for Patient Safety’s webinar training sessions next week will help builder stronger staff teams on these important foundational topics.
Tuesday will focus on how staff can use human factors to improve health care. Understanding how humans work, for both processes and equipment, can help reduce variation in health care.
NPCS will also sponsor a special session on a highly relevant change in healthcare designed to significantly improve patient safety via the elimination of tubing misconnections. Thomas Bauld, an NCPS bio medical engineer, will lead a presentation on the conversion to new tubing connectors for internal feeding.
The webinar will provide an update to recent developments and address the concerns about dosing accuracy of the current syringe for low-volume, high-potency medications.
Culture of Safety: Report Unsafe Situations
On Wednesday, the NCPS webinar will address culture, developing a fair and just culture as well as building a culture of safety. A fair and just culture is a necessary component of a Culture of Safety. Gary Sculli, Director of the NCPS Clinical Team Training program, tells us, “In a Culture of Safety, individuals are willing to self –report errors, but are also engaged in surveying the clinical environment and reporting unsafe conditions. To this end, top leaders must actively take steps to create a Just and Fair culture.
“Leaders must openly encourage reporting, take the opportunity to reward those that do so, and be sure to provide feedback that steps were taken to change and improve unsafe conditions. Leaders must champion the Root Cause Analysis (RCA) process and openly support patient safety endeavors.”
Thursday’s webinar will educate staff on the RCA process. Participants will also work independently or in small groups to create a sample action plan they can share that during the webinar. These program are aimed at all VA employees and help staff understand more about how to make patient care in the hospital even safer.
Veterans are part of the patient safety program and to be truly effective, you need to be fully informed and actively involved in your care. Here are some important Patient Safety Tips for Veterans.
About the Author: Beth J. King is the Program Manager for the VA National Center for Patient Safety