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The AHA has been working to help hospitals improve patient safety and reduce medical errors through the development of an organizational "culture of safety." Our efforts have focused on three goals:

  1. Create and enhance awareness of what constitutes a "culture of safety."
  2. Encourage an explicit organizational commitment to the development of a "culture of safety."
  3. Demonstrate organizational change that reflects implementation of the various components of a "culture of safety."

What is a culture of safety?
Ken Kizer, MD, MPH, President and CEO of the National Quality Forum, defines it this way:

"A culture of safety is an integrated pattern of individual and organizational behavior, and its underlying philosophy and values, that continuously seeks to minimize hazards and patient harm that may result from the processes of care."

How can an organization establish a "culture of safety"?
Among the critical components are:

  • Commitment of Leadership - to continual improvement in patient safety and medical error reduction as an explicit organizational priority.
    Active involvement by the organization's governing board, clinical and non-clinical leadership.
  • Open Communication - within the organization, between caregivers, and with patients about medical errors, their consequences, and the importance of patient safety.
    Patient involvement - in decisions about their health care and identifying opportunities for safety improvement; and informing them of consequences of care they receive.
    Change in language - so that language supports patient safety efforts, and does not imply judgment or placement of blame.
  • Reporting - in which all employees are encouraged to view patient safety as an integral part of their job responsibilities, and to internally report errors, "near-misses," or other opportunities to improve patient safety.
    Environment of trust - The organization needs to address accountability in a fair and just manner so that blame is not automatically placed when an error occurs.
  • Informed action - Data and information about errors and "near-misses" are collected and systematically analyzed internally on an ongoing basis, and regular evaluations of care processes are conducted to continually seek opportunities for improving patient safety.
    Understanding of systems thinking and human factors - is critical to the effective evaluation of gathered data.
  • Teamwork - in which caregivers are constantly working in a collaborative manner and where each individual has a responsibility to identify and/or act to prevent potential medical errors.
    Continual training -- in both team skills (leadership, communication, workload distribution, etc.) and job-specific competencies.

Communication with patients
Talking with patients is an important part of an organizational "culture of safety." The AHA strongly supports the need for open, ongoing communication with patients about all aspects of their health care, and the results of such care. Patients should also be involved, to the degree they are comfortable, in decisions about their health care. This allows patients to better understand the health care they are receiving as well as to shape expectations about the results of such care. Communication with the patient should not be reserved only for those instances in which an unanticipated outcome occurs.

What about Disclosure and Liability?
A new tool, developed by the American Society for Healthcare Risk Management (ASHRM), is now available on the AHA web site (www.aha.org/patientsafety). This perspectives paper, ASHRM Perspective on Disclosure of Unanticipated Outcome Information, is a helpful guide to hospitals and health care systems. It provides a practical examination of three main areas: patient issues, caregiver concerns, and issues facing health care organizations. Specifically, it provides strategies that can help organizations prepare for the disclosure of adverse or unanticipated outcomes and not subject themselves to the risk of undue liability. Finally, it outlines examples of current practices that selected institutions are using in their efforts to be open in their communications with patients.

The document recommends these to-do items:

Develop an institutional policy or position statement on disclosures of unanticipated outcomes. (We suggest consideration be give to developing this policy within the context of an overall patient information policy.)
Differentiate between disclosure of an unanticipated outcome versus an admission of liability.
Determine who will be responsible for informing the patient and, where appropriate, the family and/or legal representative, about an unanticipated outcome.
Educate caregivers and staff about your organization's policies and procedures covering this issue, and consider communications training for those charged with disclosing unanticipated outcomes.
Specify documentation requirements regarding disclosure.
Define how exceptional circumstances (abuse, compliance violations, etc.) will be managed.
Evaluate how ancillary services (behavioral health, ethics committees, social services, etc.) will be involved in cases involving disclosure.
Develop processes for continued communication with the patient, and where appropriate, family and/or legally authorized representative, after disclosure is carried out.
Provide counseling and/or support assistance for the involved health care professionals.
Identify mechanisms to coordinate with other administrative matters (adverse event reporting, patient grievance, litigation, etc.).

Other Resources
The AHA has a number of tools that can help you develop a "culture of safety" within your organization. These tools have been sent to every hospital in America over the past year:

Strategies for Leadership: Hospital Executives and Their Role in Patient Safety - a tool directed specifically for use by hospital leaders.
Strategies for Leadership: An Organizational Approach to Patient Safety - a tool, developed by VHA Inc., to help organizations evaluate opportunities to improve patient safety.
Strategies for Leadership: An Invitation to Conversation - Patient Safety - a videotape produced by the Institute for Healthcare Improvement that illustrates how leadership can be more directly involved in patient safety.

Please visit the AHA Web site's Quality and Patient Safety section at www.aha.org/patientsafety. for additional resources. Many state, metropolitan and regional hospital associations are also working on this important issue. For example, the Hospital and Healthsystem Association of
Pennsylvania has developed a new monograph, Elements of a Culture of Safety: Patient Safety is Our Top Priority. Another example is the Minnesota Hospital and Healthcare Partnership, which has produced a patient safety brochure, Redefining the Culture for Patient Safety, which describes the importance of language in creating a culture of safety. Information on both tools and other state initiatives is available at www.aha.org/patientsafety.

In addition, ASHRM is offering "Disclosure of Medical Errors: Demonstrated Strategy to Enhance Communication," a live satellite video broadcast, June 20, 2001, from 2-3 pm Eastern time. For information on these programs contact ASHRM at 312-422-3980 or visit their Web site at www.ashrm.org.


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