Paper Summary:

In this article, the writer defines and describes organizational culture driven by safety within a healthcare organization and the role of a blame-free environment within the organization used to promote safe and effective clinical care outcomes. The writer points out that with medical errors as the eighth leading cause of death in the United States--causing more deaths than breast cancer, car accidents or AIDS--healthcare leaders are looking for the right approach to the challenge of patient safety. The writer explains that a safety culture can be defined as the set of values, beliefs, and norms about what is important, how to behave, and what attitudes are appropriate when it comes to patient safety in a healthcare environment. The writer concludes that to reduce the occurrence of healthcare errors, an environment that fosters information sharing and interdisciplinary root cause analyses - not one of accusation and retribution is crucial to the success of any quality improvement initiative.

Outline:
Introduction
Safety Culture
Non-Punitive Environment
Error Management
Ethics of a Non-Punitive Environment
Conclusion

From the Paper:

"In healthcare there are several types of errors, such as near misses. Near Misses are errors that almost caused harm but did not. Near misses are often under-reported because, no harm, no foul. Adverse events include injuries that cause harm, prolonged lengths of stay due to hospital acquired complications, death, and unanticipated outcomes stemming from failure to perform a necessary treatment or intervention. By understanding human nature, no one makes an error on purpose and fear of punishment is a common reaction to making a mistake. An organization that promotes a non-punitive environment uses a root cause analyses to identify possible causes for the error, such as understanding factors that impact human performance and causes of human error. Workplace conditions that can impact human performance include reliance on memory, noise, temperature, lighting, too many hand-offs, stress and excessive noise. Human errors occur because of inattention, memory lapse, poorly designed equipment, exhaustion, and lack of training and knowledge. Errors are not disclosed because of fear of consequences to self or others, fear of being sued, the effort required to report errors including not knowing how to report errors, and lack of tools and resources to report errors. The reporting system used to report errors is a key component to error management. The error reporting system must be easy to use, not disruptive to workflow, and standardized. Error management is using all available resources and data to understand the causes of errors and take appropriate actions, such as policy change, procedural changes and training to reduce incidence of error."

Sample of Sources Used:

• Safety is a Critical Component of Quality by Medscape General Medicine, (2001). Retrieved June 20, 2008, from http://www.medscape.com/viewarticle/408114_5
• Singer, S. J. (2003). Stanford-VA Palto Alto Survey Examines Health Care Workers Attitudes toward Safety, Retrieved June 23, 2008, from http://www.apsf.org/resource_center/newsletter/2003/survey.htm
• Press Ganey Announces Safety Culture Solution for Health Care Organizations, (2007, April, 2) Retrieved June 24, 2008 from http://www.pressganey.com/safety
• Campbell D. N., Fleming, R. L., Grote, R. C., (1985)
• Interventions to Improve Safety Culture by The Emory Center on Health Outcomes and Quality ( 2004 July). Retrieved June 23, 2008 from www.gha.org/pha/resources/topics/interventionssafetyculture.pdf

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