Posted April 13, 2006
Patient Safety and Quality Healthcare: New Products
Case Studies in Patient Safety
A new study of innovative patient-safety programs found an overriding "culture of safety" that transcends the six different initiatives analyzed. "Almost everyone that gets into this business comes to believe that a culture of safety is a critical factor in changing organizational performance regarding the safety of patients," said study co-author and health-policy expert David Blumenthal, M.D.
The analysis offers health-system managers insight into the triumphs and challenges of colleagues who have tested initiatives to promote patient safety. It appears in a recent issue of Milbank Quarterly. Co-author Douglas McCarthy is president of Issues Research, an independent policy research firm based in Durango, Colo. Blumenthal is director of the Institute for Health Policy at Massachusetts General Hospital.
The Milbank study authors use a definition of safety culture originated by human-error guru James Reason. The hallmarks of a culture of safety include a climate where "people are prepared to report their errors and near-misses" and a just atmosphere where there is clear line between "acceptable and unacceptable behavior." An environment that promotes safety is a flexible culture that emphasizes teamwork.
Moving toward a safety culture often requires both revamped clinical practices and "social engineering," the authors discovered through their analysis and interviews with patient-safety leaders at the six sites.
The patient-safety innovations included an in-hospital rapid response team at one site, while another health system tested operating-room checklists and simulated crisis events on maternity wards. A Virginia hospital instituted four new strategies, among them a set of safety behavior expectations and high-priority "red rules" to remind employees of the possible harm of not following certain safety procedures.
When a new intervention encountered resistance, McCarthy said, it was often kept on track by refocusing the staff's attention on the effectiveness of the practice and patient welfare.
All six case studies report positive indicators of success — everything from a reduction in harmful medical errors to a drop in the number of hospital-acquired infections in the intensive care unit. But the results aren't sufficient to make generalizations about what works to increase patient safety across hospital settings.
Establishing a culture of safety is just one possible "lever of change" that may result in better care for patients, Blumenthal said.
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