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Opportunities for Ensuring a Safe Environment

Health care exists in an evolving political landscape. Currently, the new presidential administration is driving demand for accountability. This accountability often takes the form of demands by legislators and third party payers for assurances of patient safety and positive outcomes.

Patient safety is a complex phenomenon encompassing myriad factors and disciplines. Standards of practice must evolve in a manner that keeps pace with reality. Health care leaders must be willing to challenge the conventional wisdom that created sacred cows and to move toward evidence-based practice. Systems must encourage safety in patient care and eliminate opportunities for error. An interdisciplinary approach can refocus organizational goals so that quality and safety drive clinical initiatives. VHA is well positioned to create environments of safety because of such gold standard approaches as the Computerized Patient Record System (CPRS) and Bar Code Medication Administration (BCMA).

Organizational culture is a powerful tool that leaders use to create change and to drive operational initiatives. A nexus of safety, medication management, and informatics can set the stage for systems redesign, and creates an organizational culture that is centered on patient safety. With respect to patient safety, the concept of "just culture" has become important. As contrasted with the notion of a "no blame" culture, "just culture" seeks to promote learning through analysis of errors and near misses, as opposed to simply resorting to a disciplinary process.1

Rethinking conventional wisdom provides a basis for creating opportunities for safety. For instance, several generations of nurses have been taught that maintaining four side rails in the upright position provides safety for the patient. Evidence has demonstrated that four side rails can be detrimental to safety and should be avoided in favor of low beds, more frequent comfort rounds to eliminate the most frequent cause of falls, and reducing the incidence of polypharmacy.

Falls incidence is one of the nurse-sensitive measures closely tied to the issue of patient safety. Other measures include pressure ulcer incidence, central line infection rates, ventilator associated pneumonia, and failure to rescue. These phenomena offer opportunities to redesign practice based on evidence. While historically health care has been insular in its approach to performance improvement, contemporary practice is enriched by benchmarking from sources external to health care such as the aerospace industry for accident prevention and the hospitality industry for patient satisfaction programs. Such endeavors provide direction for creatively improving practice.

Realistically, although clinicians and administrators strive to achieve a zero defects outcome, it has to be assumed that errors will occur. Such situations must provide opportunities for learning. Root cause analysis (RCA) provides a venue to learn from clinical errors by dissecting the routes by which the error occurred, analyzing the consequences, and creating hard fixes to prevent future errors. While conventional wisdom would advocate keeping errors confidential, involving front line staff and publishing an abbreviated report of the RCA allows for learning to occur on a wider scale. Thus, evidence-based knowledge is made available to those most intimately involved in error-prone circumstances.

Medication management represents an area of risk for many health care providers, especially nurses, that can provide opportunities for learning. Individual patient risk increases with polypharmacy and the use of high-risk medications. VHA has long been a leader in medication safety with the introduction of CPRS and BCMA. Both of these products are far more than data depositories. Inherent in their creation was the design of safety devices and prevention strategies. Coupled with the performance measure and external peer review programs, it is possible to monitor practice patterns and organizational achievement of targets to determine improvement foci.

Clinical informatics is the vehicle by which safety measures are enhanced and standards of care are refined. Rather than leaving this important endeavor to a centralized "IT" department, clinician-informaticists create systems that reflect the realities of experience at the point of care and address the needs of front line staff. Systems should accomplish much more than record keeping: they must scan for iatrogenic effects of care delivery that are likely results of the increasing complexity of health care. Involving the end user in system redesign can do much to obviate the need for workarounds, which often result from system failures that did not anticipate the demands of clinical reality.

In short, the complexity of contemporary health care is fraught with opportunities for error. This environment demands an interdisciplinary approach that questions conventional wisdom and does not subscribe to the notion that accidents are largely unpreventable. New approaches refine systems of care delivery that build in safety from their inception yet acknowledge that errors provide learning opportunities. Successes and failures are shared with all care providers so that a culture of safety is created. While these efforts require a commitment of energy and resources, the stakes are far too high to gamble with the lives of our patients. Based upon its advantages in systems design and performance improvement, VHA can be a leader in reforming health care for the nation and the world.

1. Sorra JS & Nieva VF (2004). Hospital Survey on Patient Safety Culture. AHRQ Pub. No. 04-0041.


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