Staff member placing walk signs on hospital floor

How to Encourage Staff to Point out Safety Flaws

As much as healthcare organizations strive for error-free patient care, most leaders realize that there will be times when someone does something wrong. They overlook something, misinterpret directions or make a careless mistake due to stress and the inevitable hospital chaos.  Their actions may result in a near miss or a failure that leads to patient harm. The key question is, how should leaders react? And how will their response affect staff reporting of incidents and safety concerns going forward?

Incident reporting, or non-reporting, is still an issue in some healthcare settings, but major efforts are being made to change things--to encourage transparency, improve the flow of information and reinvent processes that result in improved safety for everyone involved.

Organizations must build a culture of safety, one where clinicians and other staff members are held accountable for achieving quality improvements and reporting potential safety risks, according to the National Association of Healthcare Quality’s (NAHQ’s) “Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems.”

How to Encourage Staff to Point out Safety Flaws
Susan Goodwin announced the NAHQ’s Call to Action.

“[The call to action] focuses on the importance of developing a strong safety culture within healthcare systems,” said Susan Goodwin, MSN, RN, NAHQ immediate past president and assistant vice president at HCA in Nashville, Tenn., at a press conference announcing the report.

“Studies show vibrant safety cultures are essential to recognize and mitigate sources of potential error and harm, and a strong safety culture can improve outcomes,” added Cindy Barnard, MBA, NAHQ volunteer and task team leader, director of quality strategies at Northwestern Memorial Hospital in Chicago and research associate professor at Northwestern University in the Institute for Healthcare Studies at the Feinberg School of Medicine.

Amy Clarke, BSN, RN, decentralized quality improvement specialist at Texas Children’s Hospital’s Newborn Center in Houston, agreed, saying, “Creating a culture of safety is crucial in any healthcare organization. The neonatal intensive care unit at Texas Children’s has made great strides to establish this goal.”

Greater Baltimore Medical Center (GBMC) also has made significant progress in creating a safety culture, where people feel comfortable reporting errors and near misses, said Jody Porter, DNP, RN, vice president of patient care services and chief nursing officer at GBMC. The medical center surveyed staff about perceptions of the culture and then leaders addressed concerns raised and educated staff at all levels of the organization about the need for reporting and that they would receive a non-punitive response.

How to Encourage Staff to Point out Safety Flaws
Jody Porter, DNP, RN, is creating an environment at Greater Baltimore Medical Center in which nurses feel it is safe to report errors and near misses.

“Patient safety is our top priority, and we are doing the stuff we need to get there,” Porter said.

Clarke credits participation in the Comprehensive Unit-Based Safety Program, a five-step, evidence-based program designed to permanently change a unit’s workplace culture and enable teamwork, with giving the NICU a jumpstart toward reaching that goal.

“This is achieved by empowering staff to assume responsibility for safety in their environment through education, awareness, access to organization resources and implementing teamwork tools,” Clarke said.

About the Call to Action

NAHQ convened a group of thought leaders from the American Nurses Association (ANA), the American Medical Association (AMA), The Joint Commission and other professional organizations; they polled members and drafted the call to action.

Maureen Dailey, DNSc, RN, CWOCN, a senior policy fellow with ANA’s National Center on Nursing Quality, represented the nursing association on the development of the paper.

“We have a long history of promoting patient safety,” Dailey said. “A positive culture, or a just culture, supports a positive climate, which supports multiple micro climates, such as a safety climate, and a just climate for safety reporting at the unit level in which teams work."

The call to action offers five practical suggestions to ensure the integrity of quality processes. They include:

  1. Create a focus on accountability for quality and safety as part of a strong and just culture by educating employees about reporting and publicizing ethical responses to errors and catches.
  2. Ensure that protective structures are in place to encourage reporting of quality and safety concerns, with policies that support error reporting and penalize reprisals in response to reporting.
  3. Ensure comprehensive, transparent, accurate data collection and reporting to internal and external oversight bodies.
  4. Ensure effective responses to quality and safety concerns but immediately respond to concerns.
  5. Foster teamwork and open communication and ensure effective oversight.

Barnard encourages organizational leaders to read the paper, share its findings and advance the culture changes.

“The actions recommended in the paper will serve to protect quality and patient safety, protect the integrity of the process of reporting and evaluating concerns and raise awareness among leaders and policymakers,” Goodwin added.

Encourage speaking up

In order to improve safety and quality, members of the healthcare team must speak up when they are concerned. The Institute for Safe Medication Practices has reported that 40 percent of clinicians either keep quiet or remain passive after witnessing an improper patient care event to avoid possible reprisals.

“Some healthcare organizations still lack protective infrastructure to promote and safeguard responsible reporting of safety concerns,” Barnard said.

How to Encourage Staff to Point out Safety Flaws
David Maxfield promotes better communication to improve safety.

The Silence Kills study from VitalSmarts, an evidence-based corporate training company, in partnership with the American Association of Critical-Care Nurses, found in 2005 that 84 percent of nurses surveyed said 10 percent or more of their colleagues took dangerous shortcuts. Yet less than 10 percent spoke up about their concerns. Lead researcher David Maxfield suggested establishing a team of staff and physicians to identify crucial moments when problems occur and strategies to address them.

That requires people identify areas of concern.

Goodwin added that the process by which an issue is raised is as important as the query itself. Not every concern about patient safety or quality of patient care will ultimately be deemed valid, but every reported concern deserves serious consideration.

Near misses must be reported as well as errors, so steps can be taken to evaluate processes and make improvements. Organizations must make it easy for clinicians and workers at all levels to report safety concerns.

GBMC implemented a new electronic reporting system and rolled out a reporting campaign.

At Texas Children’s, NICU nurses have numerous avenues to report any concerns. Besides the online reporting system, Safety Scoop, boxes have been placed on the unit and in the lounge where they can jot down their concerns and solution ideas.

“We then feed that information and progress back to them in the staff meetings,” Clarke said. “I also round frequently in the unit to do a pulse check. I ask the nurses if they have any concerns and if they have recently recognized any way their patient can be harmed. This openness fosters teamwork and communication.”

Another barrier, Clarke added, is concern that the reporting system is punitive.

“Now, after every event reported, we email the person who reported it and thank them for their contribution to quality improvement and patient safety,” Clarke said. “We also have the Great Catch Award. This award promotes accountability for quality and patient safety and recognizes the nurses for their contribution.”

Staff members often fail to report due to a lack of feedback about prior events and the organization’s response. GBMC creates monthly reports with information about errors and near misses, how it evaluated the event and when it resulted from a system error, what has been done to correct the process to reduce the risk of it happening again. The reports not only are distributed to managers and staff but also to the board of directors.

“It gives staff a sense of comfort that we heard what they said and we are looking out for them and our patients,” said Porter, adding, “We believe there is a need for transparency.”