Speak up for patient safety

The past year in particular has fostered the importance of patients needing to feel safe in medical surroundings. The presentation, “Patient Safety Program in Pediatric Primary Care: Speak up for Safety,” given by Cheryl Cairns, DNP, CPNP, RN at the 2021 virtual conference for the National Association of Pediatric Nurse Practitioners discussed how to ensure that the medical office is a safe place to receive care and not at high risk of medical error. Cairns noted that health care facilities are highly reliability organizations, which means that they are capable of operating under extremely trying circumstances at all times, but have fewer accidents than would be expected because of increased safeguards.

In order for health care facilities to maintain the standard of being highly reliable sites for safety, there are a number of steps that need to be met including:

• Deferring to expertise – Using the expert in the facility, rather than the overall facility authority to make decisions.
• Sensitivity to operations – Front line staff can offer the best picture of the current situation. Use them to recognize possible problems and to note opportunities for improvement. Leadership should work to ensure that there is open communication and respectful dialogue.
• Preoccupation with failure – Small and inconsequential errors should be looked at as a sign of something that’s wrong. Staff should feel comfortable about reporting concerns.
• Reluctance to simplify – Don’t say “but this is how we’ve always done it.” Clinicians and staff should be comfortable in challenging long-held beliefs. Facilities should continually review performance metrics to see if there are areas for improvement. A diversity of experience and opinion should be promoted.
• Commit to resilience – Staff should be anticipating trouble spots as well as identifying errors at the same time as creating solutions. Organizations should remove barriers that hinder the collaboration of multidisciplinary teams.

When creating a high reliability organization, the first step is to create a culture of safety, which will set the expectations for behavior that will ensure that safety is a priority. In a culture of safety there should be 3 main behavior expectations: a personal commitment to safety, accountability for clear and complete communication, and supporting a questioning attitude. With the personal commitment to safety, some methods that can help, including asking a team member to review the plan, which promotes working together and checking one’s work or thought process, while another method is taking the time to stop and think about what needs to be done, which should ensure attention to detail. If concerns are discovered, a health care professional should clearly explain it, suggest a review of it, work on developing a consensus of next steps, and escalate the concern to higher-ups when necessary. Discussion of concerns should not occur in front of patients or families.

The second behavioral expectation of clear and complete communication may be the most important one. Cairns noted that previous research conducted over the course of 10 years from 1995 to 2005 showed that ineffective communication in a team was the cause for roughly 66% of all medical errors during that period. Additionally, the Joint Commission’s Sentinel Event database found that communication issues were the leading cause of sentinel events in the United States. Developing strong patient-provider communication is one key to improving overall communication and should include clear setting of expectations, ensuring that the patient plays an active role in the dialogue, and focusing on the exchange of direct information. One technique to ensure good communication is the “repeat and read back” technique. Using this technique, one writes or states the information clearly, repeats back information to ensure accurate understanding of the information; and acknowledge the accuracy of the information. Clinicians should also encourage the asking of clarifying questions.

The final behavioral expectation is to support a questioning attitude. When faced with information, a health care provider should qualify the source of the information, validate whether it made sense to her or him, and check the information against an independent and expert source. If a health care provider is uncertain in a situation, he or she should take the time to stop and review, reassess, and resolve the uncertainty before going forward with care.