Academic journal article Frontiers of Health Services Management

Patient Safety: What Is Really at Issue?

Academic journal article Frontiers of Health Services Management

Patient Safety: What Is Really at Issue?

Article excerpt

SUMMARY

The Veterans Health Administration found that a number of components were key to implementing a meaningful and effective patient safety program. To truly improve patient safety, the overall goal of your organization must be to prevent harm to the patient, not to eliminate errors. Create a system that is perceived as fair, and mitigate perceived barriers to improving patient safety. Create a transparent system for prioritizing and establishing how resources will be applied to the patient safety effort. Provide tools that support root cause analysis that moves beyond superficial and inadequate questions such as, Whose fault is this? Action that results in improvement, not simply analysis of the problem, is needed. Finally, leadership and management must be visibly involved in the patient safety program.

ARTICLES HAVE BEEN published around the world for decades chronicling the injuries that are inflicted on patients while they are being provided medical care (Kohn, Corrigan, and Donaldson 2000; Australian Health Ministers' Advisory Council 1996; Brennan et al. 1991; Baker et al. 2004; Baker and Norton 2004; Steel, Gertman, and Crescenzi 1981; Steel et al. 2004; Gopher 2004; Donchin et al. 2003), yet there is still a long way to go before a major dent is made in this problem. While "patient safety" is a term that is thrown around quite freely in a variety of situations, unfortunately, very little has changed since it first burst into the public's and general medicine's consciousness with the release of the Institute of Medicine's (lOM's) To Err Is Human report (Kohn, Corrigan, and Donaldson 2ooo). There are a number of reasons for this, ranging from a lack of acceptance that a problem even exists to an actual or perceived misalignment of incentives and goals. Said another way, it can be thought of as a combination in varying degrees of ignorance and arrogance.

Rather than just cover these issues from a strictly theoretical standpoint, this article presents experiences and findings from an actual patient safety program successfully implemented by the National Center for Patient Safety (NCPS) at the Veterans Health Administration (VA). Several components of the VA's program are described in the article, including the following:

i. Leadership must create an environment of acceptance by the entire organization and communicate relentlessly-both in word and in deed-that patient safety is the foundation on which quality healthcare is built. If the patient is not safe from accidental harm, then high-quality care cannot exist.

2. Establish a clear definition of the over-all goal as being one to prevent inadvertent harm to the patient, not the misguided goal that concentrates inordinately or exclusively on eliminating errors.

3. Create a system that is perceived as fair. Identify the barriers that staff perceive to improving patient safety and then mitigate them. One example is the explicit definition of what will be considered to be blameworthy (i.e., actions that can result in punitive measures against the actor/offender) and what possible actions can be taken to respond to a blameworthy event.

4. Create a transparent system for prioritizing and establishing how resources will be applied to improving patient safety. An individual's "expert" opinion alone is not supportable in any credible way to outside critics.

5. Provide tools that facilitate a human-factors-engineering approach to root cause analysis that moves beyond superficial and inadequate questions such as, Whose fault is this? to the more meaningful and productive questions such as, What happened? Why did it happen? and What do we do to prevent it from happening in the future?

6. Leadership and management must be visibly involved in the patient safety program in an explicit manner that is publicly verifiable. This involvement can take the form of having patient safety reports and discussion as the first agenda item for every management and board meeting. …

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