Patient Safety and Healthcare Quality

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Advocate Excellence:Measures In Developing A Reporting Culture

By Marionette Cortez posted 01-21-2019 19:36

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Topic Brief:
 Safety lapses can be prevented before they occur when fully addressed and resolved in a timely manner between staff and leadership.Staff needs to be responsible for their actions and report right away safety issues occurs.Once the incident is determined,the leading officer should listen and act appropriately to prevent harm to patients. The Joint Commision's complimentary publication,Sentinel Event Alert#60.Developing A Reporting Culture:Learning from Close Calls and Hazardous Conditions,addresses this issue at the Heart Reliability Healthcare. Four essential Measures in Developing Culture has been discussed.
1. Trust Establishment
Do what is right,regardless of personal risk. Patient care should always comes first. Staff should not be afraid of reprisal if they were to report safety issues. Leaders should listen to their staff and help create the personal responsibility being demonstrated by staff to establish a clear performance expectations among employees within a psychologically safe environment in which there is no fear of negative consequences for reporting mistakes that when staff report close calls and hazardous conditions,leaders can act by addressing concerns resulting in improvement and safety . It is easy to say than done,but every year The Joint Commission receives report from healthcare staff of unsafe conditions in some facilities which states that leadership is not responsive to early warnings,even though their reaction may have prevented harm events from occurring. Complacency toward risk is dangerous and should not be tolerated. This norm of a "no harm,no foul" attitude may leave a near miss or at-risk behavior unreported,fostering conditions that may eventually result in harm. That is why leaders must engage all staff in an effort to promote trust and improve reporting results. It is a must to identify and report unsafe conditions before they can cause harm,trusting that other staff and leadership must act on the report,and taking personal responsibility for one's action are critical to creating a safety culture and nurturing high reliability within a healthcare organization.
2.Fear of Punishment Elimination
Punishment leads to fear,psychological tension and anxiety,which may interfere with worker's desire to behave properly.Adopting a just culture is critical to eliminating fear of punishment,and that leadership must gradually change the culture so that the need to report and do something about a safety issue outweighs the fear of being punished. Provide the staff with psychological safety to speak up and engage in process improvement that can have a positive impact on these efforts.Again,it is easy to say than done.According to a survey in 2018 by US Agency for Healthcare Research and Quality(AHRQ) that 47 percent of respondents said that it feels like unsafe event reports are held against them and 50 percent of respondents indicated that after an event,it feels like the person is being written up, not the problem .So a guid​elines has been put into considerations about near misses and close calls reported by staff.​These guidelines are applicable to all employees at all levels and are held to the same standard.
a. All staff must see that those making human errors will be consoled
b. Those responsible for at-risk behaviors will be coached
c. Those committing reckless acts will be disciplined fairly and equitably regardless of outcome
3.Reporting Encouragement
         In a safety culture,healthcare organization leaders should develop a reliable system,an incident reporting system that report close calls,near miss and hazardous or unsafe conditions that is accessible,easy to use,deliver timely analysis data and should give a feedback loop to let employee know action is being taken to address or fix the identified safety issue. The system should also include recognition program to those who report adverse events and communicate success stories about errors.Staff must fully understand that those who report human errors and at-risk behavior will not be punished and that it will serve as a learning process  and make improvements in the future.
4.Close Calls and Unsafe Condition Evaluation
         Close Calls are defined as unsafe acts and procedure violations that could have seriously harmed a patient but did not because they were identified,reported,addressed,and solved in the nick of time. It is a must to report close calls for the following reasons:
a. To provide information on active and potential weakness in healthcare safety system
b. They occur frequently that events causing real harm to patients
c. The high frequency analysis of near miss reports helps identify possible weakness of healthcare and learn from it in the context of daily
         Evaluation and gathering of datas are so important and must be put into use in identifying error-prone situations and identifying the system if it works properly.