Patient Safety Initiatives

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Medicine is considered a high-risk system with a high error rate, but these two characteristics are not always correlated. Other high-risk industries have managed to maintain an impeccably low error rate.

The nuclear submarine program is an example of an organization that has achieved the distinction of being considered a “high reliability organization.” High reliability organization theory recognizes that there are certain high-risk industries and organizations that have achieved very low accident and error rates compared to what would be expected given the inherent risks involved in their daily operations. Other high reliability industries and organizations include aircraft carrier flight decks, nuclear power plants, and the Federal Aviation Administration’s air traffic control system. In fact, one reason why nuclear power plants have such an excellent reliability record may be that their operators are often former naval submarine officers whose previous experience and training within one highly reliable organization are easily transferable to other organizations.

One of the assumptions underlying the science of high reliability organizations is that humans who operate and manage complex systems are themselves not sufficiently complex to sense and anticipate the problems generated by the system. This introduces another important idea undergirding the science of patient safety: the concept of normal accident theory. Instead of attributing accidents to individual error, this theory states that accidents are intrinsic to high-volume activities and even inevitable in some settings. Accidents should not be used merely to identify and punish the person at fault, but should be seen as a systems problem and addressed at a broader level. As Ruchlin states, even the “best people can make the worst errors as a result of latent conditions.”

High-risk systems, as defined by Perrow in 1984:

  • Have the potential to create a catastrophe, loosely defined as an event leading to loss of human or animal life, despoiling of the environment, or some other situation that gives rise to the sense of “dread.”
  • Are complex, in that they have large numbers of highly interdependent subsystems with many possible combinations that are nonlinear and poorly understood.
  • Are tightly coupled, so that any perturbation in the system is transmitted rapidly between subsystems with little attenuation.

However, high reliability organization theory suggests that proper oversight of people, processes, and technology can handle complex and hazardous activities and keep error rates acceptably low. Studies of multiple high reliability organizations show that they share the following common characteristics:

  • People are supportive of one another.
  • People trust one another.
  • People have friendly, open relationships emphasizing credibility and attentiveness.
  • The work environment is resilient and emphasizes creativity and goal achievement, providing strong feelings of credibility and personal trust.

Developing these characteristics is an important step toward achieving a low error rate in any organization. For this reason, safety culture is a measure used by hospitals nationwide to improve outcomes and is increasingly recognized as a metric of hospital quality.

Figure legend: Root causes of sentinel events 2004 to 2012. (Data from The Joint Commission, 2012.)

Board Review Questions

1. The Donabedian model of measuring quality identifies all of the following as main types of improvements EXCEPT

A. Changes to structure


B. Changes to process


C. Changes to culture


D. Changes to outcomes

2. The root cause of the majority of wrong-site surgeries result from

A. Communication errors 


B. Emergency surgery


C. Multiple procedures


D. Multiple surgeons

3. The most frequent nosocomial infection is

A. Urinary tract infection (UTI)


B. Sepsis


C. Pneumonia


D. Fungal infection

Answers

1. The correct answer is C. Changes to culture 

2. The correct answer is A. Communication errors 

3. The correct answer is A. Urinary tract infection (UTI) 

Gerard Doherty

Moseley Professor of Surgery, Harvard Medical School, Surgeon-in-Chief, Brigham Health & Dana-Farber Cancer Institute

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