requires skillful leaders with exceptional communication abilities.
Source: Used with permission from the U.S.A. Government.
A strong safety culture begins with leadership; their behaviors and actions set the bar. I urge all health care leaders to make safety culture a top priority at their health care organization. Establishing and improving safety culture is just as critical as the time and resources devoted to revenue and financial stability, system integration and productivity—because a lack of safety culture can have serious consequences for patients, staff and other stakeholders.
Ana Pujols McKee, MD, Executive Vice President and Chief Medical Officer,
The Joint Commission (TJC, 27 December 2017, para. 6).
OBJECTIVES
Upon completion of this chapter, the reader should be able to:
1 Describe the current state of quality and safety in health care organizations.
2 Define High Reliability within healthcare settings.
3 Evaluate the characteristics of high reliability organizations (HROs).
4 Analyze the impact of Quality and Safety Education for Nurses (QSEN) competencies on high reliability.
5 Discuss nursing's role in high reliability organizations.
6 Identify resources nurse leaders can use to foster a culture of high reliability.
OPENING SCENARIO
Ms. Smith's daughter Kali is a patient in the Neonatal Intensive Care Unit (ICU). Ms. Smith diligently pumps her breasts to provide nourishment to her newborn. After pumping, Ms. Smith gives the milk to the nurse, who labels it and places it in the refrigerator. The next day, the nurse prepares a feeding for Kali. After administering the feeding, the nurse notices that the milk is labeled with Ms. Brown's name.
By definition, this is a serious safety event. The organization takes immediate action: it notifies both Ms. Smith and Ms. Brown, and tests Ms. Brown for a variety of infectious diseases. In addition, the error is thoroughly investigated by a team that includes nurses, nursing assistants, physicians, and staff from infection prevention, risk management, quality, information technology, and administration. The team conducts a root cause analysis to determine the underlying cause of the breast milk mis‐administration and creates a corrective action plan. The executive leadership team and board of directors review the information and approve the corrective action plan. Everyone at the hospital expresses confidence that the processes put into place will prevent this event from happening again. Unfortunately, within a few months, the incorrect breast milk is administered to a baby in the pediatric department.
The Institute of Medicine (IOM, 1999) described the safety of U.S. health care in To Err is Human. They suggested that 44,000–98,000 people die in hospitals each year from medical errors that could have been prevented and provided a roadmap to safety. The IOM outlined strategies to prevent errors, including enhancing knowledge about safety; identifying and learning from errors; raising expectations for improving safety; and implementing safety systems in health care organizations to ensure safe practices at the patient care delivery level. Seventeen years later, Makary and Daniel (2016) estimated that medical errors cause 251,000 deaths each year. This makes medical errors the third leading cause of death in the Unites States (U.S.) after heart disease and cancer.
Safety is the responsibility of every nurse and each member of the interprofessional team. Despite the heavy focus on quality and safety, errors continue to occur. Nursing managers and leaders are in a unique position to foster a culture of high reliability. This chapter will describe the current state of quality and safety in health care organizations. After defining and evaluating the characteristics of HRO s, the chapter will analyze the impact of QSEN competencies on high reliability. Last, the chapter will describe the role of the nurse in creating a culture of safety and identify resources nurse leaders can use in a journey toward high reliability.
Definitions of Error
Health care is dangerous, and mistakes or errors can have devastating consequences for patients and staff. Nurses and other health care professionals do not come to work intending to harm patients. However, humans make mistakes. It is part of the nature of being human. Most medical errors do not result from individual recklessness. Instead, many medical errors are caused by faulty health care systems, processes, and conditions that lead people to make mistakes or fail to prevent them. This means that health systems can best prevent mistakes by creating processes that make it easier to do the right thing and harder to do the incorrect thing.
Internal Standards
An error is defined as a deviation from generally acceptable performance standards. Performance standards may be found within a health care organization or may exist external to the organization. Internal standards include policies, procedures, protocols, and order sets.
External Standards
External standards include professional practice standards and practice requirements imposed by accreditation.
Near Miss Safety Events
An error may cause varying levels of harm to a patient. A near miss safety event occurs when the safety event doesn't reach the patient because it is caught by chance or because the process was engineered with a detection barrier. For example, Ms. Johnston and Ms. Johnsen may both be hospitalized on the same nursing unit. The nurse may accidently bring Ms. Johnston's medications to Ms. Johnsen. By properly identifying the patient using two unique identifiers, this error can be identified before causing harm to the patient. Nurses often fail to report Near Misses, rationalizing that no one was hurt. However, near miss safety events serve as an early warning system of something that could go wrong. By reporting near miss safety events, health care organizations can work on improving processes so that no one else makes the same error.
Precursor Safety Events
Precursor safety events occur when the health care error reaches the patient and results in no harm or minimal detectable harm. For example, the nurse may do a finger stick to check a blood sugar for Ms. Johnston when it was ordered for Ms. Johnsen. The error has reached the patient but has resulted in minimal harm, in this case a finger stick. Like near miss safety events, precursor safety events should be reported so that they can be used to improve care.
Adverse Events and Serious Events
Adverse events or serious safety events occur when the error reaches the patient and results in moderate to severe harm or even death.
Sentinal Events
Sentinel events are a subcategory of adverse events. A sentinel event is a patient safety event that is not primarily related to the natural course of the patient's illness or underlying condition, reaches the patient, and results in death, permanent harm, or severe temporary harm (TJC, January 2018). For example, imagine
