Anyone following the news of RaDonda Vaught, a former nurse in Nashville, Tenn., surely is saddened by the tragedy of the situation for all involved—the families who suffered this loss and those who feel any responsibility towards its creation. The case serves as a sobering reminder that both workforce and patient safety is the No. 1 job of all of us leading healthcare organizations.
Vaught’s conviction has generated strong reactions from many of us in healthcare, particularly and understandably from those in nursing, who now worry that setting a precedent of criminalizing medical mistakes will discourage nurses and other healthcare workers from reporting them. Worse yet, the conviction has cast a shadow of fear in all of us. That’s a serious concern.
Preventable medical errors are regrettable and should be avoided at all costs, but the cause of errors is often the failure of a system rather than the individual. We are human, and human beings are not perfect. Not reporting an error after it happens introduces the risk of it repeating, which can lead to the very thing we must avoid—patient harm.
Hospitals and health systems need leaders who support cultures that focus on addressing systems issues that contribute to errors and harm, and healthcare workers must be encouraged to report errors, lapses, near-misses and adverse events when they occur. Those points are made clear in Leading a Culture of Safety: A Blueprint for Success, an evidence-based resource ACHE developed in partnership with the Institute for Healthcare Improvement’s Lucien Leape Institute to help leaders create and sustain a culture of safety in their organizations.
The Blueprint is organized into six leadership domains, one of which is “Lead and reward a just culture.” That means clinicians and others in our workforce are supported when systems break down and errors occur. And while individuals need to be held accountable for at-risk behavior, we have an equal responsibility to look at the systems that brought us to an event and correct imperfections and defects. Developing a just culture is much more than a policy or a principle, it is an ever-present, organization-wide, systematic practice for all those working in a healthcare organization. The guidance in the Blueprint is invaluable, and I strongly encourage any healthcare leader, no matter where his or her organization is on its respective safety journey, to download it.
The Blueprint is available on ACHE’s Leading for Safety webpage, which links to a number of other safety-related tools and resources as well. That includes the Safety Pledge, in which leaders can make a formal commitment to prioritize safety, and the Culture of Safety self-assessment, a questionnaire to help them determine what safety measures are working in their organization and where improvements can be made.
In addition, an ACHE white paper looks at the critical role CEOs play in leading a culture of safety and driving sustainable patient safety improvements in their organizations. The paper is the result of extensive research ACHE conducted with hospital CEOs about the prevalence of certain patient safety practices recommended in the Blueprint. Summaries of the research and a report on the findings also are available.
Leaders also can refer to Safer Together: A National Plan to Advance Patient Safety, an action plan for health systems to use in efforts to eliminate preventable medical harm. Developed by ACHE and members of the National Steering Committee for Patient Safety, the plan is the work of 27 influential federal agencies, safety organizations and experts, and patient and family advocates brought together by the IHI. The document offers 17 recommendations to advance patient safety through such areas as culture and leadership, patient engagement, workforce safety and learning.
We cannot move forward if fear is dictating our environment. Ensuring the safety of patients starts with establishing a just culture—a transparent one in which everyone feels comfortable identifying and pointing out errors—in the organizations that care for them. Human error is inevitable, so the systems we put in place, and our willingness to address issues within them, are essential to making progress on the journey to zero patient harm. No matter where you are in your safety journey, ACHE is here to support you in advancing safety and equity for all.
Anthony A. “Tony” Armada, FACHE, is executive vice president and chief transformation officer, Generations Healthcare Network, Lincolnwood, Ill. He also serves as Chair of the of the American College of Healthcare Executives.