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Building a Culture of Patient Safety

As reported by the Institute of Medicine, medical errors are the fifth leading cause of death in the United States and cost a staggering $29 billion annually. Patient safety has become a major concern in the U.S. health care system and the VHA as well. Cynthia Caroselli describes the complexities in the health care arena that affect patient safety, including issues at the point of care delivery as well as political influences that shape the culture of the VHA. She argues that the VHA is well positioned to be a leader in patient safety, and analyzes two critical considerations about patient safety in the VHA to which I would like to respond.

The first consideration is that an interdisciplinary approach is needed to create a culture of patient safety. She provides several examples of contributions from nurses to monitor and improve patient safety and states that patient safety in the VHA can be enhanced by systems such as the CPRS and BCMA. This is all true and the VHA has made some significant contributions to patient safety. However, more information about interdisciplinary collaboration to improve patient safety is needed. More research and program evaluation is needed to evaluate the outcomes of interdisciplinary approaches to patient safety. Patient safety is not discipline-specific and yet, much of the responsibility rests with nurses. Some interdisciplinary strategies have been proposed, however, including the importance of communication.

One example of an interdisciplinary approach that could improve patient safety is developing interdisciplinary patient care standards and evidence-based practices.1 Other examples include interdisciplinary approaches to teamwork, shared governance, and patient rounds, all of which have been found to improve patient safety.2 We also need to develop an effective infrastructure to support interdisciplinary monitoring to reinforce that patient safety is a shared responsibility. These interdisciplinary approaches may help health care organizations create a culture of patient safety, reduce costs, and save lives.

Caroselli's second point is that not all errors are preventable and that when they do occur, organizations should use these events as learning opportunities. This point is an important one. The challenge for the VHA is to use system re-design methods to convert health care organizations into learning organizations. Organizations that develop into learning organizations have the ability to identify knowledge gaps, trust opposing views, reflect on experiences, and tolerate errors. Bureaucracy and political environment influence the culture of the VHA, which may discourage reporting of errors and unintentionally impose penalties for errors. These influences may decrease the likelihood that errors will be acknowledged.

These processes may preclude a culture of patient safety that is based on the tenets of a learning organization. The political environment often creates a protective response from leaders that may shape the organization toward a restrictive system that is hesitant to openly acknowledge and deal with errors. The three building blocks for learning organizations to develop are: 1) a supportive learning environment; 2) concrete learning processes; and 3) leadership that reinforces learning.3 These building blocks provide a structure for assessing performance and identifying areas for improvement to promote a learning organization.

Integrating three powerful processes: developing interdisciplinary approaches to patient safety, creating learning organizations that support a culture of safety, and the research expertise in the VHA will increase performance and reliability of services in health care. Innovations being developed in patient safety centers of excellence provide a unique opportunity to evaluate structure, process, and patient safety outcomes using research methods. As the VHA continues its strong commitment to system re-design processes, it is more likely to become a true learning organization. However, leaders will have to embrace leadership styles that promote trust and that view errors as learning opportunities. Nursing leadership teams can define strategies for developing interdisciplinary teams to monitor and promote patient safety. The VHA is committed to building a culture of safety across the continuum of care, including home care--an often overlooked area for promoting safe environments for Veterans. The VHA is well positioned to build research programs to test organizational strategies for each of the building blocks of learning organizations and to disseminate research-based information to help leadership teams use these strategies to build a stronger culture of safety in their facilities. Linking the VHA research expertise with evaluation of innovative strategies will make a significant contribution to promoting safe care for Veterans.

  1. Hougaard J. Developing Evidence-Based Interdisciplinary Care Standards and Implications for Improving Patient Safety. International Journal of Medical Informatics 2004, 73(7), 615-24.
  2. Sherwood G, et al. A Teamwork Model to Promote Patient Safety in Critical Care, Critical Care Nursing Clinics of North America 2002, 14(4), 333-40.
  3. Garvin DA, Edmondson AC, and Gino F. Is Yours a Learning Organization? Harvard Business Review 2008, 86(3), 109-116, 134

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