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Chapter 2 Patient Safety Culture
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Chapter 2: Theories of Patient Safety
To create sustainable improvements in safety, it is necessary to create a culture of safety. This chapter introduced the key theories and approaches to developing a safety-based culture locally.
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Why is safety ‘culture’?
“The safety culture of an organisation is the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety management.”
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What is safety culture Culture is learned, not biologically inherited
What we do What we think What we produce = the outcomes All based on our mental processes, beliefs, knowledge, and values Adapted from Reason
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WHAT WE PERMIT WE PROMOTE
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Key characteristics of safety culture…
Mutual trust Shared perceptions on the importance of safety Confidence in the efficacy of preventive measures Safety culture
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Resources Manchester Patient Safety Scales (MaPSaf)
Sexton Safety Attitudes Survey Experience of Care Survey SHINE Tool
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The Model for Safety Culture
No time for safety or investment into improvement Pathological Safety occurs in response to an incident Reactive Safety is driven by management systems and imposed on the workforce Bureaucratic There is value placed in safety with continually improving systems Proactive The ideal, where safety is an integral part of everyday life in all staff Generative Hudson P. Applying the lessons of high risk industries to health care Qual Saf Health Care 2003
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Swiss Cheese Model Reference James Reason
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Where is healthcare? We embrace procedures
Self-reflection is encouraged Safety tends to come from management It is regarded that healthcare is current in the reactive-bureaucratic stage in its maturity.
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Where is healthcare cont.
Generative Proactive Increasing informedness Bureaucratic Increasing trust Reactive Pathological Hudson P. Applying the lessons of high risk industries to health care Qual Saf Health Care 2003
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How can we mature into a proactive organisation?
Reporting Safety Management Systems Reporting: Reporting scientific fact is well established Rates of reported individual and systematic failures are poor This can be improved by removing blame culture Investigation: Standardise incident investigation procedures Attitudes: Increase ownership of safety and improvement amongst all staff Encourage a flat hierarchy Encourage increased self-reflection Increasing open channels for communication between all staff Safety Management Systems: Medical procedure and pharmacological risk are well documented Improved understanding of systematic and operation risk is needed Investigation Attitudes
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How can we map progress? Manchester Patient Safety Framework (MaPSaF)
Facilitate reflection on patient safety culture Stimulate discussion about the strengths and weaknesses of the patient safety culture Reveal any differences in perceptions between staff groups Help understand how a more mature safety culture might look Help evaluate any specific intervention needed to change the patient safety culture MaPSaF is a tool that has been developed to help healthcare teams and organisations reflect on their progress in developing a mature safety culture. It can help healthcare staff explore their level of development of the safety culture of the team in which they work. A team uses a form to evaluate and reflect on its maturity within each of the dimensions of safety culture. It is recommended that MaPSaF is used at least once a year with each healthcare team. By using MaPSaF at regular intervals, it is possible to chart progress in developing a mature safety culture. › Home › Patient safety resources
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Foundation for safety A safety policy Organisational arrangements to support safety A safety plan A means of measuring safety performance A feedback loop to improve safety performance Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013.
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A framework for the measurement and monitoring of safety
Past harm Past Harm Reliability Sensitivity to operations Anticipation and preparedness Integration and learning Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013.
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Moving from Risk Management to Safety 1
Compliance with standards Complete Partial None Risk Registers Current? Meaningful? Acted upon? Responding to complaints Timely Remedial action Incident reporting and Investigations Serious case reviews RCA Measurement of quality and harm continually Trigger tool Daily measures Measurement for improvement Run charts & SPC Improvement methodology Small scale test of change PDSA Strategic Alignment Driver diagrams Process changes Human Factors understanding Communication e.g. SBAR Situational Awareness Design changes Incident trees NHS III
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Moving from Safety 1 to Safety 2
Things that Are difficult but go right Early completion Excellent innovation Things that go wrong Positive surprises Unwanted Outcome Planned Great outcome Hollnagel E., Wears R.L. and Braithwaite J. From Safety-I to Safety-II: A White Paper. The Resilient Health Care Net
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The ‘huddle’ suite: Achieving situation awareness
Escalate Leaders Daily Safety Brief Overview of events of harm and risk Mitigate Ward Safety Huddle Nurses, Doctors, Allied professionals PEWS, Watchers, family or communication concern Identify Ward Bedside huddles Nurse Doctor Parent
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Reliable Communication
I-S-B-A-R Identify Situation Background Assessment Recommendation and Read back
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Ten suggestions for harm-free paediatrics Fitzsimons J and Vaughan D Patient Safety (P Lachman, Section Editor) Current Treatment Options in Pediatrics December 2015, Volume 1, Issue 4, pp No or minimal pain and distress No tissue injury—extravasation, pressure ulcer or other tissue injury No hospital-acquired infections No medication or fluid injuries Early recognition and management of procedural or surgical complications Early recognition and management of sepsis or other life-threatening illnesses Early recognition and management of in-hospital deterioration Early recognition and management of safeguarding concerns No unnecessary admissions, investigations, procedures or treatments No psychological harm—provide a positive experience
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Daily questions to ask at all levels
What did we do well? So we can replicate Past harm Has patient care been safe in the past? Reliability Are our clinical systems and processes reliable Sensitivity to operations Is care safe today? Anticipation and preparedness Will care be safe in the future? Integration and learning Are we responding and improving?
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