Establishing a Culture of Safety in Your Institution
December 2002 newsletter
It has been estimated that for each accident there are ten incidents. For each incident there are 100 near misses/close calls. For each near miss/close call, there are 1000 unsafe (latent) conditions…” (SSM, October 2002).
Increasingly, the health care industry is starting to realize that errors are due to systems failures. This is a new way of thinking about errors. The predominant culture of humiliation, shame, and blame is slowly being replaced by a "Blame Free" environment. It has been recognized that most errors occur because the system set up the health care provider for failure, and if it had not happened to a particular nurse, it most likely would have happened to another RN under similar circumstances.
Blame free does not mean that a health care worker can be negligent in his or her practice. It is however, an attempt to increase reporting of system issues. We are unable to fix problems if we do not know they exist. Investigations of errors in a Blame Free environment focuses primarily on processes, and not people.
Problems within systems may be thought of as "system pathogens." These pathogens include poor system design, poor procedures, lack of supervision, inadequate training, and understaffing. These are examples where an error is lurking in the shadows, waiting to happen. They are also opportunities for improvement, once brought to light.
The health care industry is notoriously behind other industries, such as the airline industry and the petroleum and chemical industries, in establishing a culture of safety in hospitals. When the Institute of Medicine published their report "To Err is Human," patient safety was all of a sudden on the forefront. Although we are all committed to patient safety, this is not something which happens overnight. Creating a culture of safety presents many challenges. We must recognize the presence of differing cultural perspectives might be the origin of misunderstandings, and ultimately establish the basis for sentinel events. It is important to realize that each culture has unique political skills and power tactics used for individual and collective purposes. We might concede that information sharing is not universal, nor consistent across cultural components in an organization. Consider the differences between perspectives of surgeons, nurses, techs, and anesthesia providers, and acknowledge that respect and trust between cultures vary according to the perceived status of the culture and the value of the contributions made by each cultural group.
One of the leaders concerning patient safety standards is the JCAHO. They mandate that leaders engage, lead, and provide resources for patient safety initiatives. The ultimate goal is to create a climate conducive to proactive patient safety efforts that engage all health care facility staff members, patients, and their families. Some of the 2003 patient safety goals published by the JCAHO includes improving the accuracy of patient identification, improving the effectiveness of communication among caregivers, and to eliminate wrong-site, wrong-patient, and wrong procedure during surgery.
A successful safety culture program reflects the characteristics of a true learning organization. Reporting is encouraged, as well as initiatives and innovative ideas. Responsibility tends to be shared. Engaged and involved key players at all levels will ensure an enthusiastic effort!
By Sophie Taylor, President
The President Speaks!
October 2002 Newsletter
Greetings fellow AORN members,
It was a pleasure seeing such a great turnout at our first meeting of the year. Thank you all who attended. We hope you will make our meetings part of your monthly professional practice update. Some things will be done differently in the meetings this year. For example, there will not be a “roll call” on all the committees for reports. Only those committee chairmen who get in touch with me to have their reports on the agenda will be giving their reports. This also brings me to my next point. The Legislative Committee needs a chairman. The person in this position would help keep the chapter updated in the legislative arena. To make this job easier, National AORN sends out updates every month. In addition, there are four ORNCC meetings to attend every year (optional, but strongly encouraged). ORNCC is a group made up of representatives from the various chapters in California. ORNCC pays very close attention to what happens in the legislature. In order to have input into the laws that affect our practice, we must be active and make sure our voice is heard. Other duties of this office include writing articles for the newsletter about the ORNCC meetings, and periodic updates if an issue is on the horizon. The time requirement is approximately two to three hours per month. Let me know if you would like to be a part of this committee. Contact information is on the last page.
Other updates:
* Perioperative Nurse Week is coming up November 10-16. The slogan this year is “Your safety is our job… We take it seriously” (don't ask me where they got that catch phrase from…). AORN members are encouraged to promote awareness of this week as an immediate follow-up to state and federal elections, establishing a base of contact with elected officials, community leaders, and public policy makers.
* The ballot for National Office 2003 is out. Bill Duffy and Anita Jo Shoup are running for President-Elect. Our chapter delegation wants to hear your opinion regarding who to vote for, and how you want us to vote on the issues at Congress.
I hope you all have a wonderful fall. Let us know if you have any plans for Perioperative Nurse Week so we can share these ideas with everyone.
By Sophie Taylor, President
Patient Safety First, Last, and Always
August 2002 Newsletter
By Sophie Taylor
“If 99.9 % were good enough:
-The IRS would lose over two million documents this year
-There would be a major plane crash every three days
-16,000 items would be lost in the mail every hour
-12 babies would be given to the wrong parents every day
-107 erroneous medical procedures would be performed each day.”
This was a quote from the “Patient Safety First” web site at www.patientsafetyfirst.org. Medical errors have been on the forefront ever since the Institute of Medicine (IOM) came out with their report “To Err is Human” which states that between 45,000 to 90,000 patients die every year due to human error. What has become increasingly clear is that the old “blame and train” environment does not reduce errors. The clear message from the IOM report is that safety is primarily a systems problem. Therefore, better systems have to be developed to help prevent errors, and these systems must be developed to ensure that clinicians can provide the effective care they intend to provide.
Are the policies and procedures in place to support the practitioner in their caregiving? For example, when a nurse monitors a patient undergoing moderate sedation (formerly known as conscious sedation), is there a policy in the facility that lists the criteria for a nurse to monitor the patient (i.e. ASA level) vs. when the anesthesia department is a better choice? If the policy states RNs can monitor patients up to an ASA II, and the nurse is faced with a level III patient, then the nurse can respectfully decline based on that particular protocol. This is a policy supportive of our practice.
Safe care ingredients include the identification of what works, ensuring the patient receives it, and delivering it flawlessly. Sounds noble in the world of managed care, cutbacks, drawbacks, downsizing and rightsizing. However, healthcare organizations are being forced to respond to the patient safety issues. Our friend, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now issues Sentinel Event Alerts which the accredited hospitals have to act upon and respond to. One example which is relevant to the operating room is side and site issues. What is the best practice to avoid wrong site surgery? What safeguards do we have in place to protect the patient from having surgery on the wrong leg? This is a systems issue, and when something goes wrong, one has to look at that system. What are the checks and balances?
Improving communication in the surgical suite has proved to be a key issue. This includes involving the patient as part of the team. Nurses have been trying to accomplish this for years, and we have often been frustrated by external pressures such as rapid room turnover time (which sets us up for errors), and surgeons who rush us. AORN has had position statements on things like this for years, and I believe OR nurses are light years ahead of others when it comes to patient safety. We have always been advocates for those who cannot speak for themselves due to being under general anesthesia or heavy sedation. One last thought in error prevention is that a practice known to reduce errors in other industries is the limitation of work hours.
President’s Corner
June 2002 Newsletter
Dear distinguished colleagues,
It was a pleasure serving you at Congress in Anaheim this year. The arrangements were excellent, and classes were, for the most part, very interesting. The House of Delegates and the Forums were rather chaotic, and we debated some very important issues which I will talk about more in my Congress report.
Congratulations to Mary Ritchie (our newsletter goddess) for the AORN Chapter Newsletter Award for Intermediate-sized chapters! Mary works really hard at editing our newsletter (thank you so much!). The important thing about our newsletter is that it is of a consistently high quality. To keep this quality up, articles are encouraged from the membership.
AORN did a couple of things differently this year, which in my opinion were very innovative and forward thinking. They let student members attend Congress for free. This allowed one of our newest members, Jackie Cummings, to participate and discover what a fantastic organization we have!
Another new feature was Part I of a two-part leadership seminar (the second will be in Denver this summer). “Nuts and Bolts of Chapter Leadership” was presented by Louis Benson, PhD. The speaker had some concrete ideas for how to conduct meetings, recruit new members, and strategic planning. All this gave me some ideas for what to do in the future. We have to focus our precious energy in a couple of areas. Increasing membership will be at the forefront. Continuing to provide excellent educational sessions at the chapter meetings will also be a priority, as well as keeping current with the developments in the legislative arena. In the fall, I hope to kick off a membership drive. If everyone can bring one person to the September meeting, we would be off to a great start! I would like everyone to sign up as a membership ambassador. Let’s challenge ourselves to bring our chapter membership up to 200! For this to succeed, everyone has to help. Our chapter has a large number of RNs who will be retiring in the next few years. Ask yourselves what makes it hard for you to attend, and if there is anything we can do to help alleviate that.
The nursing shortage and overtime hours makes it hard for tired nurses to volunteer time. Some people have children who need their attention. Would child care during the meeting time be helpful to any of you? Let me know so that we can arrange for a baby sitter.
Times are changing, and we need to be proactive in order to thrive. We can make it happen, help it happen, and watch it happen!
By Sophie Taylor