Patient Safety Culture: The Nursing Unit Leader's Role
Discussions about a culture of patient safety abound, yet nurse leaders continue to struggle to achieve such a culture in today's complex and fast-paced healthcare environment. In this article the authors discuss the concept of a patient safety culture, present a fictional scenario describing what happened in a hospital that lacked a culture of patient safety, and explain what should have happened in the above scenario. This discussion is offered within a framework consisting of seven driving factors of patient safety. These factors include leadership, evidence-based practice, teamwork, communication, and a learning, just, and patient-centered culture. Throughout, an emphasis is placed on leadership at the unit level. Nurse managers will find practical examples illustrating how leaders can help their teams establish a culture that offers the patient quality care in a safe environment.
It has been more than 10 years since the Institute of Medicine (IOM) released its report, To Err is Human: Building a Safer Health System. This report, edited by Kohn, Corrigan, and Donaldson (2000) laid out a four-tiered approach for improving patient safety: (a) establish a national focus to create leadership, research, tools, and protocols around patient safety, (b) identify and learn from errors, (c) raise performance standards for improvements through the action of oversight organizations, purchasers of healthcare, and professional groups, and (d) create safety systems at the delivery level. Because creating safety systems at the point-of-care delivery was the ultimate target of all the IOM recommendations, the IOM committee continued to emphasize that healthcare organizations should create an environment in which safety was a top priority. It described a safety culture as one that focused on preventing, detecting, and minimizing hazards and error without attaching blame to individuals (Kohn, Corrigan, & Donaldson). The report emphasized the need for leaders at the clinical, the executive, and the governing board levels to take ownership for patient safety.
The IOM report (Kohn, Corrigan, & Donaldson, 2000) quickly elevated awareness of patient safety. Within weeks of the report's release, the United States (U.S.) Congress initiated hearings on medical errors and patient safety issues (Leape, Berwick, & Bates, 2002). The National Quality Forum (NQF), the Joint Commission (TJC), and the Agency for Healthcare Research and Quality (AHRQ) developed and/or continued to accelerate work around patient safety. The Quality and Safety Education for Nurses (QSEN) project developed guidelines that would enable future nurses to have the knowledge, skills, and attitudes necessary to improve the quality and safety of the healthcare systems within which they work (QSEN, n.d.). These groups, along with many other federal, state, and professional organizations, recognized that a patient safety culture was integral to improved safety outcomes and became the drivers for new policies and standards. In this article the authors will discuss the concept of a patient safety culture, present a fictional scenario describing what happened in a hospital that lacked a culture of patient safety, and explain what should have happened in this scenario. This discussion will be offered within a framework consisting of seven driving factors of patient safety culture. These seven factors are presented in the Figure, originally published by Sammer, Lykens, Singh, Mains, & Lackan (2010). Throughout, an emphasis will be placed on leadership at the unit level. Nurse managers will find practical examples illustrating how leaders can help their teams establish a culture that offers the patient quality care in a safe environment.
Abstract and Introduction
Abstract
Discussions about a culture of patient safety abound, yet nurse leaders continue to struggle to achieve such a culture in today's complex and fast-paced healthcare environment. In this article the authors discuss the concept of a patient safety culture, present a fictional scenario describing what happened in a hospital that lacked a culture of patient safety, and explain what should have happened in the above scenario. This discussion is offered within a framework consisting of seven driving factors of patient safety. These factors include leadership, evidence-based practice, teamwork, communication, and a learning, just, and patient-centered culture. Throughout, an emphasis is placed on leadership at the unit level. Nurse managers will find practical examples illustrating how leaders can help their teams establish a culture that offers the patient quality care in a safe environment.
Introduction
It has been more than 10 years since the Institute of Medicine (IOM) released its report, To Err is Human: Building a Safer Health System. This report, edited by Kohn, Corrigan, and Donaldson (2000) laid out a four-tiered approach for improving patient safety: (a) establish a national focus to create leadership, research, tools, and protocols around patient safety, (b) identify and learn from errors, (c) raise performance standards for improvements through the action of oversight organizations, purchasers of healthcare, and professional groups, and (d) create safety systems at the delivery level. Because creating safety systems at the point-of-care delivery was the ultimate target of all the IOM recommendations, the IOM committee continued to emphasize that healthcare organizations should create an environment in which safety was a top priority. It described a safety culture as one that focused on preventing, detecting, and minimizing hazards and error without attaching blame to individuals (Kohn, Corrigan, & Donaldson). The report emphasized the need for leaders at the clinical, the executive, and the governing board levels to take ownership for patient safety.
The IOM report (Kohn, Corrigan, & Donaldson, 2000) quickly elevated awareness of patient safety. Within weeks of the report's release, the United States (U.S.) Congress initiated hearings on medical errors and patient safety issues (Leape, Berwick, & Bates, 2002). The National Quality Forum (NQF), the Joint Commission (TJC), and the Agency for Healthcare Research and Quality (AHRQ) developed and/or continued to accelerate work around patient safety. The Quality and Safety Education for Nurses (QSEN) project developed guidelines that would enable future nurses to have the knowledge, skills, and attitudes necessary to improve the quality and safety of the healthcare systems within which they work (QSEN, n.d.). These groups, along with many other federal, state, and professional organizations, recognized that a patient safety culture was integral to improved safety outcomes and became the drivers for new policies and standards. In this article the authors will discuss the concept of a patient safety culture, present a fictional scenario describing what happened in a hospital that lacked a culture of patient safety, and explain what should have happened in this scenario. This discussion will be offered within a framework consisting of seven driving factors of patient safety culture. These seven factors are presented in the Figure, originally published by Sammer, Lykens, Singh, Mains, & Lackan (2010). Throughout, an emphasis will be placed on leadership at the unit level. Nurse managers will find practical examples illustrating how leaders can help their teams establish a culture that offers the patient quality care in a safe environment.