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Journal of Nursing Administration:
doi: 10.1097/NNA.0b013e3182346eae
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A Framework for Patient Safety, Part 2: Resilience, the Next Frontier

Blouin, Ann Scott PhD, MBA, RN, FACHE; McDonagh, Kathryn J. PhD, RN, FACHE, FAAN

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Author Information

Author Affiliations: Executive Vice President (Dr Blouin), The Joint Commission, Oakbrook Terrace; Vice President, Executive Relations (Dr McDonagh), Hospira Inc, Lake Forest, Illinois.

The authors declare no conflict of interest.

Correspondence: Dr Blouin, The Joint Commission, 1 Renaissance Blvd, Oakbrook Terrace, IL 60181 (ablouin@jointcommission.org).

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Abstract

Last month in Part 1, the authors discussed the critical aspects associated with building a safety culture and holding staff and leadership accountable through measurement and expected performance. Sustaining a safety culture begins with the human aspects but must reach beyond the underlying systems and processes, which enable resilience and error prevention in today's complex healthcare environment.

In the last decade, the boundaries and theory of safety principles in organizations began to expand. The term resilience became a part of safety parlance to describe organizations that were able to achieve ultra-high levels of safety despite high risks, difficult tasks, and constantly increasing pressures.1 Resilient organizations according to Woods et al1 are proactive and adaptive, which means that they not only have high safety levels but also cope well with the unexpected. In other words, resilient organizations do not wait for errors or "close calls" to occur to make corrections; they focus on anticipating changes in risk and plan for adaptation.

The relatively new concept of resilience engineering has a different view of adverse events than has existed in healthcare. Rather than treating adverse events as something to track, analyze, and follow-up (often in a punitive manner), they are seen as signals in a complex environment that require adaptations to maintain safety in a constantly changing milieu.

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Resilience in Healthcare

The studies of resilience engineering come from industries that have highly complex and error-prone businesses where the risk of failure has dire consequences, such as aviation, chemical engineering, and nuclear power production. These companies are referred to as high-reliability organizations (HROs), which are characterized as having extremely strong cultures of safety that permeate the organization. According to the Agency for Healthcare Research and Quality (AHRQ), which supports the movement of healthcare towards high-reliability practices, the goal of high-reliability thinking is to create culture and processes that radically reduce system failures and effectively respond when failures do occur.2 Some believe that hospitals are far from being HROs and that the path to achieve this goal will be long because of the complexity and uniqueness of hospitals. The variations in hospital procedures and the dynamic role of human beings as both caregivers and patients add layers of complexity not yet fully understood. Some of the healthcare organizations cited by AHRQ as leaders in safety were Sentara Health System, which established daily safety huddles that became a habit in the organization and helped reinforce the importance of the sensitivity to operations. Multiple-purpose rounding by supervisors and administrators also reinforced the criticality of operations and focus on the patient experience, safety, and teamwork.

Cincinnati Children's Hospital is recognized nationally for its focus on patient safety and quality. The organization used 5 elements on their journey: leadership, institutional infrastructure and resource investment, rigorous measurement, transparency, and accountability. Importantly, the leaders transformed the organization by aligning strategic planning with the investments being made in safety and quality improvement.2

Ascension Health set high aspirations with its program Healing Without Harm, which is part of its strategic initiative to provide safe healthcare. The program has a focus on falls, pressure ulcers, perinatal safety, nosocomial infections, perioperative safety, Joint Commission national patient safety goals (NPSG), and adverse drug events.3 These healthcare systems are representative of leading organizations that are taking an assertive approach to becoming HROs and committing to patient safety from the boardroom to the bedside.

Another role model for addressing patient safety in a systematic way is the "Seven Pillars" program at the University of Illinois Medical Center at Chicago (UIMCC). McDonald et al4 describe their program that was intended to provide all members of the UIMCC with the confidence and resources to adopt a culture of safety, transparency, inquiry, and medical error disclosure. In a resilient fashion, the program was designed to rapidly learn from, respond to, and modify practices based on investigation to improve the safety and quality of patient care. The 7 pillars encompass patient safety incident reporting, investigation, communication and disclosure, apology and remediation, system improvement, data tracking and performance evaluation, and education and training. In the 2 years since implementation, this approach has resulted in significant system improvements and an emerging culture of safety and transparency.

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Human Factors

Another area of focus being applied to improving resilience in healthcare involves the study of human factors. More studies are being done to analyze cases with errors and what can be done to prevent these based on human error theory.5 This analysis is translating to changes in practice including redundant safety checks to assist practitioners who may be in an automatic mental mode and miss subtleties such as look-alike drug names or duplicate patient names. Practitioners like nurses who are repeatedly interrupted or multitasking are prone to inadvertent errors; so practices like the wearing of medication vests are used to minimize those disruptions during complex processes such as medication administration.

Medication administration is a process fraught with complexities and hand-offs in healthcare organizations. This process requires a thorough assessment of each process component and the application of technology to prevent medication errors. Many healthcare organizations approach their technology application to this process in a "piecemeal" fashion, thus not achieving systemic improvement in preventing medication adverse events. Studies report found that integrated medication delivery systems can significantly reduce medication errors, costs, and excess hospital days.6

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Clinical Team Involvement

One imperative in improving safety systems is to involve the frontline practitioners in developing new processes, along with the need to constantly adapt these practices to maintain a safe environment. Often times, when the involved providers are not included in developing safe practices and creating a resilient organization, they will develop "workarounds" to be able to accomplish their work. These practitioners may not be aware that workarounds result in unsafe situations because they are focused on accomplishing their patient care goals yet creating margins for error.

Workarounds are often a result of the larger system not considering the required workflows of practitioners. An example of a workaround that resulted from introducing a safety technology, bar coding for medication administration, is that nurses will create additional patient arm bands that can be scanned with the bar code near the medication administration cart and then carry the medications to the patient to be administered without bar coding at the bedside. This bypasses the safety feature of ensuring that the 5 rights of medication administration are in compliance through bar coding at the point of administration. It is a result of the entire process of medication delivery not being analyzed and planned in the context of how it will impact the workflow of the pharmacists, nurses, and other practitioners. Nurse executives play a critical role in ensuring all professional disciplines are involved in creating safe and effective workflows.

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Health Information Technology: Impact on Safety

As more healthcare processes are automated through technology, it is critical to consider the safe implementation of healthcare information technology (HIT). The American Recovery and Reinvestment Act of 2009 provides financial incentives for eligible healthcare providers to implement HIT. Healthcare providers have to demonstrate compliance with "meaningful use" criteria to be eligible to receive the incentive payments. This advancement in HIT should have many positive benefits to patient care delivery, but caution should be taken that this influx of new technology does not introduce new safety issues.

The Joint Commission sentinel event alert entitled "Safely Implementing Health Information and Converging Technologies"7 addresses just such issues in the field. The alert advises users to be mindful of safety risks and preventable adverse events, as HIT is increasingly adopted in healthcare organizations. In particular, converging technologies (which are the interrelationships between medical devices and HIT) are highlighted. Examples of such devices include infusion pumps, patient-controlled analgesia, ventilators, computerized provider order entry, bar coding, and automated dispensing cabinets. Many healthcare organizations have disparate systems and medical devices that operate independently and may not interface. This can create opportunities for adverse events, because providers may not be able to view all the relevant information about a patient in 1 place or at 1 time. It is essential that as healthcare organizations assess their information needs and add systems to their HIT portfolio, they consider safety factors and interoperability. Lancaster General Health took such an approach when they worked with 2 major vendors to implement their autoprogrammed "smart" infusion system, which interfaces safety software with bar coding and the electronic health record.8 This is an example of the power of collaboration and interoperable systems creating synergy for patient quality and safety.

Austin et al9 describe the many barriers to HIT adoption including cultural, behavioral, technical, and organizational issues that need to be anticipated and addressed. A strategy roadmap should be used that includes engaging leadership, clearly communicating the vision, identifying and analyzing the stakeholders, recruiting project champions, motivating change, and executing.

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Summary

Safe patient care is an aspiration for healthcare providers and organizations throughout the country, yet is an elusive concept given the myriad complexities that make up our healthcare system today. In the decade since the publication of the Institute of Medicine report To Err Is Human, some progress has been made in addressing safety issues; yet it is just the beginning of a journey towards a systematic approach to providing safer care. There are no quick fixes in addressing patient safety issues. In fact, quick fixes can often result in additional unintended consequences that perpetuate unsafe environments. Healthcare organizations must become HROs, which means embarking on the long and arduous pathway to building a culture of safety and organizational design that incorporates principles of resilience engineering. This 2-part series-"A Framework for Patient Safety"-describes the equal importance of culture as experienced by healthcare staff and leadership, combined with engineering resilience and reliability into technology. The resulting integration of systems and processes to help people move beyond "try to do your best" holds promise to actually prevent mistakes and improve quality. The promise of our healthcare system is to provide safe, effective, and affordable care; yet that promise is not being fulfilled in many instances according to the National Priorities Partnership, a coalition of major national organizations that collectively influence every part of the healthcare system.10 We must fundamentally change the ways we deliver care. Isn't that change worth keeping the promise to those we serve?

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References

1. Woods D. Resilience engineering: Redefining the culture of safety and risk management. Hum Factors Ergon Soc Bull. 2006;49:12.

2. US Department of Health & Human Services. Agency for Healthcare Research and Quality: Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. April 2008. No. 08-0022.

3. Ascension Health Annual Report 2010. Available at www.ascensionhealth.org. Accessed October 12, 2010.

4. McDonald T, Helmchen L, Smith K, et al. Responding to patient safety incidents: the seven pillars. Quality Safe Health Care. Available at qshc.bmj.com. Accessed March 1, 2010.

5. Duthie E. Application of human error theory in case analysis of wrong procedures. J Patient Saf. 2010;6:2.

6. Anderson J, Jay S, Anderson M, Hunt T. Evaluating the capability of information technology to prevent adverse drug events: a computer simulation approach. J Am Med Inform Assoc. 2002;6:2.

7. Safely implementing health information and converging technologies. The Joint Commission Sentinel Event Alert. Issue 42. Available at http://www.jointcommission.org/assets/1/18/SEA_42.PDF. Accessed April 17, 2011.

8. Pregulman S, Rinda J. Building a plug-and-play future for healthcare. Available at http://www.mddionline.com/article/building-plug-and-play-future-healthcare. Accessed September 23, 2011.

9. Austin G, Klasko S, Leaver, W, et al. The art of health IT transformation. Bull Natl Center Healthc Leadersh. 2009:5-16.

10. National Priorities Partnership Convened by the National Quality Forum. National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare. Washington, DC: National Quality Forum; 2008.

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© 2011 Lippincott Williams & Wilkins, Inc.

 

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