Implementing Just Culture to Improve Patient Safety

Let's Talk Safety - Data from the Neonatal Intensive Care Unit Safety and Bed Capacity Huddles

BACKGROUND

Huddles are brief team meetings designed to communicate essential information. Safety huddles provide a forum to identify and review patient safety events. In a just culture, everyone is accountable for patient safety.

PURPOSE

The purpose of this project is to discuss safety issues/events at the twice daily bed capacity huddles in a Level IV Neonatal Intensive Care Unit (NICU) utilizing a just culture model. Having daily discussions of patient safety and the escalation process for follow-up promotes a just culture. The aims are to improve the unit's culture of safety and learn from patient safety issues.

METHODS

A just culture model was adopted to promote discussion of safety events during the huddles. A structured checklist of safety events was utilized along with a script of ground rules. Twice a day, a multidisciplinary group gathers to huddle. Nurse leaders facilitate the discussion, track the results, and provide follow-up.

RESULTS

The structured safety huddle began in May of 2020 and continues twice daily. All required staff attend. The escalation process is defined and has prevented recurrence of some safety issues. The NICU experienced a 14% increase in favorable results on the Agency for Healthcare Research and Quality (AHRQ) culture of safety survey since the inception of the structured safety huddles.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Safety huddle discussions have impacted the culture of safety on this unit. Tracking of discussions can help to identify trends, improve processes, and impact patient safety.

Exploring the perception of safety culture among nurses in Saudi Arabia

BACKGROUND

Medical errors and adverse events pose a serious challenge to the global healthcare industry. Nurses are at the frontline in implementing safety measures and protecting patients. This study aimed to investigate nurses' perceptions of the patient safety culture in Saudi Arabia.

METHODS

This cross-sectional descriptive study used convenience sampling to survey 402 nurses from various hospitals in Jazan, Saudi Arabia. The Hospital Survey on Patient Safety Culture was used for the data collection.

RESULTS

Nurses reported a moderate perception of safety culture, with 60% positive responses. Teamwork had the highest safety culture rating at 77.8%, while responses to error and staffing were the lowest at 39.75% and 46.17%, respectively. Qualifications significantly predicts nurses' safety culture rating (B = -0442, t = -4.279, p < 0.01). Positive correlations were found between event reporting frequency and communication openness (r = 0.142, p < 0.01), and patient safety grades with communication about errors (r = 0.424, p < 0.01) and hospital management support (r = 0.231, p < 0.01).

CONCLUSIONS

Nurses in Saudi Arabia demonstrated a strong sense of teamwork and commitment to organizational learning. However, critical areas such as staffing and error response require attention to improve patient safety.

Perceptions of medical error among general practitioners in rural China: a qualitative interview study

BACKGROUND

Medical error (ME) is a serious public health problem and a leading cause of death. The reported adverse incidents in China were much less than western countries, and the research on patient safety in rural China's primary care institutions was scarce. This study aims to identify the factors contributing to the under-reporting of ME among general practitioners in township health centres (THCs).

METHODS

A qualitative semi-structured interview study was conducted with 31 general practitioners working in 30 THCs across 6 provinces. Thematic analysis was conducted using a grounded theory approach.

RESULTS

The understanding of ME was not unified, from only mild consequence to only almost equivalent to medical malpractice. Common coping strategies for THCs after ME occurs included concealing and punishment. None of the participants reported adverse events through the National Clinical Improvement System website since they worked in THCs. Discussions about ME always focused on physicians rather than the system.

CONCLUSIONS

The low reported incidence of ME could be explained by unclear concept, unawareness and blame culture. It is imperative to provide supportive environment, patient safety training and good examples of error-based improvements to rural primary care institutions so that ME could be fully discussed, and systemic factors of ME could be recognised and improved there in the future.

Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame

PURPOSE OF REVIEW

Despite healthcare workers' best intentions, some patients will suffer harm and even death during their journey through the healthcare system. This represents a major challenge, and many solutions have been proposed during the last decades. How to reduce risk and use adverse events for improvement?

RECENT FINDINGS

The concept of safety culture must be acknowledged and understood for moving from blame to learning. Procedural protocols and reports are only parts of the solution, and this overview paints a broader picture, referring to recent research on the nature of adverse events. The potential harm from advice based on faulty evidence represents a serious risk.

SUMMARY

Focus must shift from an individual perspective to the system, promoting learning rather than punishment and disciplinary sanctions, and the recent opioid epidemic is an example of bad guidelines.