Keeping Patients Safe Transforming the Work Environment of Nurses (2004) / Chapter Skim
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2 A Framework for Building Patient Safety Defenses into Nurses' Work Environments
2 A Framework for Building Patient Safety Defenses into Nurses' Work Environments
Pages 53-64
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From page 53... ...
and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 20011. To Err Is Human identifies a national agenda for change, specifying actions that entities primarily those external to organizations directly delivering health care (Congress, regulators, accreditors, public and private purchasers, health professional licensing bodies, and professional societies)
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From page 54... ...
the environment of policy, payment, regulation, accreditation, and similar external factors that shape the environment in which health care delivery organizations deliver care. Whereas To Err Is Human speaks mainly to the fourth level, Crossing the Quality Chasm addresses primarily the first and second levels how the experiences of patients and the work of Microsystems of care, such as health care teams, nursing units, or individual health care workers delivering care to patients, should be changed (Berwick, 20021.
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From page 55... ...
This framework integrates the multiple, mutually reinforcing strategies that are needed within various components of the work environment to keep patients safe from the ever-present latent conditions and human errors that pose risks to patient safety (as described in Chapter 11. THE NEED FOR BUNDLES OF MULTIPLE, MUTUALLY REINFORCING PATIENT SAFETY DEFENSES Research from a variety of disciplines clearly documents that errors and adverse events, especially those that are difficult to correct, often result from multiple, interdependent factors that converge to impair the performance of organizations (Goodman, 2001; Perrow, 1984; Ramanuajm, forthcoming)
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From page 56... ...
Stuclies of high-reliability organizations also have iclentifieci multiple, related practices associated with the achievement of high levels of safety in production processes. These inclucle ensuring ongoing vigilance of workers to detect unexpected sequences of events that pose the risk of errors; constantly training workers in knowing how to detect errors in the making and respond to errors once they occur; incorporating personnel and equipment reclunciancy in work design; managing work flow, especially in interclepenclent work components; and practicing nonhierarchical decision making so that decisions are macle at that point in the organization where expertise is greatest often the point where the action is to be implemented, which can often be at lower levels of the organization's hierarchy (Roberts, 1990; Roberts and Bea, 20011.
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From page 57... ...
The committee noted evidence that patient safety is threatened by inadequate staffing levels, long work hours, poor education and training, unsafe work practices, underutilization of information technology, and a variety of other work conditions. It also quickly became apparent that these are not competing, but complementary views of the threats to patient safety.
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From page 58... ...
· Productive activities are the actual performance of humans and machines used to "deliver the right product at the right time." · Defenses include structural and procedural safeguards to prevent foreseeable injury, damage, or costly outages. Reason notes that each of the above elements of the production process is shaped by the fallible decisions and actions of humans, thereby creating the ever-present risk of error.2 2While Reason notes that a similar schema could be presented for purely mechanical or technical failures, he, like the committee, focuses on human factors because accident analyses reveal these to be the dominant factors in the production of errors.
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From page 59... ...
A(~(:lnFNT LIMITED WINDOW OF ACCIDENT OPPORTUNITY FIGURE 2-2 Human contributions to error within each production component. SOURCE: Reprinted with the permission of Cambridge University Press from Human Error by James Reason, copyright 1990.
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From page 60... ...
As Figure 2-3 illustrates, these recommendations are aimed at creating work environments with built-in patient safety defenses that include (1) adopting transformational leadership and evidence-based management practices, (2)
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From page 61... ...
The implementation of these recommendations should recognize the unique features of health care that make it especially vulnerable to error production and escape from detection and remediation. UNIQUE FEATURES OF HEALTH CARE THAT HAVE IMPLICATIONS FOR PATIENT SAFETY DEFENSES In his more recent studies of patient safety, Reason has identified characteristics of the health care industry that distinguish it from other high-risk industries and make it more vulnerable to the production and effects of errors.3 These include the greater diversity and associated risks of actions undertaken in health care, the greater vulnerability of health care consumers, differences in the delivery of health care services in contrast to other human services, the uncertainty of the health care knowledge base, and the less explicit and open investigation of errors.
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In the commercial aviation and nuclear power production industries, pilots and nuclear power plant operators spend the greater part of their time performing routine control and monitoring activities (mostly the latter)
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From page 63... ...
Summary In summary, health care institutions are complex systems, and their complexity includes features that are less often present in the kinds of hazardous hi-tech systems that are often used as models for effective safety management. This does not mean that health care professionals cannot learn valuable safety lessons from these other domains; rather, HCOs, policy officials, nurses, and all parties working to increase patient safety need to be mindful of the distinctive features of health care delivery that make it even more susceptible to the production of errors.
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From page 64... ...
Human resource bundles and manufacturing performance: Organizational logic and flexible production systems in the world auto industry. Industrial and Labor Relations Review 48:197-221.
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