Challenge 1

Creating a Culture of Safety

Executive Summary Checklist

Achieving a culture of safety in a healthcare organization requires transformational change which is owned and led by the executive leaders of the organization, including the board, encouraging accountability and transparency. Leadership’s primary goal must be to make their hospital a safe haven for patients.

  • Address unexpected outcomes with open disclosure and prompt resolution.
  • If patient harm results from a preventable medical error, adopt the CANDOR (Communication and Optimal Resolution) Approach: apologize as soon as possible, pay for all care related to the preventable harm, seek a just resolution, and provide ongoing support for patients and families. Clinicians (the “second victims” of patient harm events) may also require attention and support (Lambert et al., 2016).  
    1. Create an open and transparent culture that encourages staff to speak up and self-report
    2. Apologize within 30 minutes
    3. No charge for care
    4. Credit card for follow-up care
    5. Incentivize lawyers to settle fast
    6. Do event reviews to avoid reoccurrence
    7. Within 30 days of any event disseminate learning out to the patient, family, hospital system and externally
  • Create a standard of care to ensure that clinicians speak with family members to explain what will be changed so this event won’t happen again. Offer family members an opportunity to be involved and witness the change in procedure, etc.
  • Create a reliable means to capture and analyze good catches/near-misses.  Set a goal that includes aspirations that all errors and incidents are preventable and that zero is the most important goal.
  • Implement an electronic adverse event reporting system that allows for anonymous reporting, tracking, trending and response to aggregate safety data.
  • Implement thoughtful and memorable internal branding to keep safety expectations and aligned behaviors top of mind throughout an organization.

The Performance Gap

Despite widespread efforts among healthcare organizations to improve patient safety and healthcare quality, preventable patient deaths still occur. It is estimated that there could be over 200,000 preventable patient deaths per year in U.S. hospitals alone, and up to one-third of patients unintentionally harmed during a hospital stay (James, 2013;
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