During the weeks before writing this column, I had conversations with people from different professions, all seeming to ask the same question: Are hospital administrations and health care providers creating a “safety culture”? Safety culture—sure, we have implemented approaches to make our system safer. We emphasized “no-blame” reporting, among other things. But to my astonishment, my response was incorrect. No, I was told—that was not what they meant. What they wanted to know was whether the people were embracing the culture. That question was the impetus for the topic this month.
Since the publication of the seminal 1999 work To Err is Human by the Institute of Medicine,1 health care professionals, the industry, and consumers have striven to reduce and prevent medical errors. Systems have been developed and introduced to mitigate the potential for accidental injury or death in hospitals and other health care facilities. In some instances, insurers—both private and public—have begun to impose fines or have denied payment for services provided that were necessitated by a medical error. Yet despite these improvements, preventable errors persist, and the resulting costs—in quality of life, lives lost, and monetary measures—continue to mount.
Too frequently, we cause harm or fail to deliver the optimal benefits of our health care system. Initially, frustration with our error-vulnerable system was sufficient impetus to get us moving toward changing the status quo and committing ourselves to make our health care system a better, safer industry. More importantly, we strove to organize what was a “non-system,” in our determination to substantially improve the quality of health care in our country. Alas, we continue to struggle with the same (or at least similar) issues with quality that have created the chasm2 between the health care system we have now and one we know we could have.
After more than a decade of learning, listening, and teaching about health care quality, system-wide improvements, and the implementation of various tools to close that chasm, I wonder whether we are missing what might be the real bridge across the abyss. Have we made that quantum leap from fixing the blame to fixing the system? Have we become educated about an actual culture of safety in addition to educating ourselves on the mechanics of safety initiatives? We have changed the system to some degree, but have we truly changed the culture?
“Safety culture”—what did my colleagues mean? Off to the Internet I went, exploring the difference between what I thought I was promoting and what I was missing. Seems I had some gaps in my knowledge. And of course, in my own backyard were some of the innovators of what is known as the “Just Culture”3 or the “Fair and Just Culture.”4 Simply put, this means “giving constructive feedback and critical analysis in skillful ways, doing assessments that are based on facts, and having respect for the complexity of the situation.”4 It also means creating effective organizations that allow and encourage people to divulge their errors, and helps each organization’s team to learn from those errors.
In many instances, we continue to condemn and take disciplinary action against those who make an honest mistake, admit to it, and ask for help or provide insight in order to prevent similar occurrences in the future. By responding in this way to our colleagues who err, we run the risk of remaining unaware of the extent of errors and injuries and their consequences. There, I think, is where we miss an important opportunity to progress in moving our health care system forward.
We need to take steps toward securing free and uninhibited reporting.3 In this scenario, everyone functioning in our institution has the responsibility to identify, and the opportunity to remedy, any situation that might result in error or injury, or that has already had such a result. We know that error analysis—even of errors that do not cause injury—gives us the opportunity to identify system improvements that can prevent adverse events. But until and unless we become open and support the practice of admitting to an error—or reporting a situation in which an error occurred or could have occurred—the opportunity to mitigate the flaws that contributed to the event is lost. And that is the true tragedy: that we fail to learn from untoward events or errors. We are thus doomed to repeat them, both in our own facilities and across the entire health care system.
It is imperative for all disciplines to know that disclosing an unsafe situation or error is an opportunity to educate others about the risk and use pertinent information to improve the working and care environment. We need to change the focus in our system-wide culture from one that blames the individual provider to one that seeks to learn from the error. And we need to be honest with ourselves: In many situations, we have only given lip service to the concept that divulging errors should not result in punitive actions. This does not mean that we are relieved of accountability for the care we provide; rather, we remain obligated to act responsibly and function within our qualifications. In addition to the actions we take, we are also accountable to discuss errors of commission or omission, and to identify process improvements and/or systems corrections.4
Just as we have seen in the airline industry, it is time to change our culture of fear and defensiveness to a true “safety culture,” with a structure in which people can openly divulge their errors or report potential hazards, allowing the organization to learn from them. Until we fully embrace that approach, I fear it will take another decade before we can have a safe health care system.
1. Kohn LT, Corrigan JM, Donaldson MS, eds; Committee on Quality of Health Care in America, Institute of Medicine, National Academy of Sciences. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
2. Committee on Quality Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century (2001). www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed November 21, 2012.
3. Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. New York, NY: Columbia University; 2001.
4. Dana-Farber Cancer Institute Principles of a Fair and Just Culture. www.macoalition.org/Initiatives/docs/Dana-Farber_PrinciplesJustCulture.pdf. Accessed November 21, 2012.