This is Nursing Management's annual, award-winning safety issue, and looking back on the year, safety issues abounded. We discussed many in these editorial pages, including the dreaded culture of blame, psychological safety, staffing, ownership versus accountability, and getting back to quality. Following the thread of this year's issues does wind around safety; it's clearly front and center. Are the issues stubborn or solvable?
Let's talk frankly. What are the concerns at the point of care? This was the year of the RaDonda Vaught conviction. Safety culture was jeopardized all over the country. The upside was a galvanized reaction to do better from healthcare systems, nursing professional organizations, and most nurses. Would you and your organization support any team member who makes a mistake? Paradiso reports in her article in this issue that per the 2021 Agency for Healthcare Research and Quality safety culture survey results, 55% still feel mistakes are held against them. Will this ever budge?
Another frustrating issue is that the science of human factors and systems engineering isn't the standard approach to design, procedures, and workflows. It's needed to build processes that work for staff and patients, and it must involve the front line. Without understanding the real world of patient care, we can't design safe and risk-mitigating workflows. Leaders should be doing the “gemba” walk—actually observing the work. There are many reasons not to use this improvement methodology, including organizational culture, time and effort involved, staff engagement, and lack of trained facilitators. The tendency to “hold people accountable” doesn't drive systems approaches and impedes progress in error prevention.
Technology can potentially prevent harm, and there's empirical evidence it does, especially surrounding the myriad medication processes and clinical decision-making. One promising technology advance is harnessing and integrating artificial intelligence, which could enhance some higher-level cognitive functions and help us with decision support, prediction, and prevention.
There is a caveat: we've all learned that technology alone won't solve problems; it's the triad of people, processes, and technology that does. Addressing all three when creating safety solutions is critical to successful results, and not always done. Even barcoded patient ID systems have eluded safety. Workarounds, for this and other supposed “standard work,” tend to indicate systems issues, not people issues. And don't get me started on alarm and alert fatigue; it seems to get worse, not better, as confirmed by studies. It's gone on too long to be considered an unintended consequence, and we all know that flourishing alerts and alarms invite lack of attention. Yet we still add more.
Another intractable issue is age-old: communication. How many harm events have you investigated this year alone that could have been mitigated or even prevented by effective communication? Technology is helping here but doesn't replace humans. Communication can be taught. TeamSTEPPS is one example of teachable structured effective communication. Why isn't it a standard to teach essential communication to clinicians?
I've focused on our front line and their intersection with stubborn safety issues. You can take a much broader view and look at data analytics at micro and macro levels, governance, organizational culture, leadership, resources, structures, reporting, EHR optimization, innovation, modern learning systems including simulation, and so much more. Stubborn or solvable? I think both.