Tackling the Top 10 Patient Safety Concerns with a Culture of Safety – Part 1

The ECRI Institute recently published their Top 10 Patient Safety Concerns for Healthcare Organizations for 2017. Several of these items were on last year’s list, which means we in healthcare still have work to do to drive improvement and meet targeted goals.

Aside from just highlighting new and recurring safety concerns, this list is also a great starting point for inspiring patient safety discussions and setting priorities in your own organization. Here are some ways you can target these concerns by developing a culture of safety.

Let’s begin by counting down, David Letterman style, from ten to one. Since there is much we can say about each finding, we will be covering only 5 safety concerns in this article and the remaining 5 in a second article.   

10. Inadequate organization systems or processes to improve safety and quality


There are numerous studies that link error prevention to a culture of safety—being proactive and setting strong preventive strategies rather than waiting for patients to be harmed. This is such an important issue that the Sentinel Event Alert recently addressed the essential role of leadership in developing a safety culture.

Unfortunately, healthcare has been very slow to adopt a culture of safety. Let’s take a look at exactly what a culture of safety is and how leadership is essential to creating one in an organization.  


What is a “Culture of Safety”?

Safety cultures have been around a long time, but they’ve only recently been adopted in healthcare. High-reliability organizations are committed to safety by consistently minimizing adverse events at all levels, from frontline providers to managers and executives. This commitment establishes a culture of safety built around the following 7 pillars:

  1. Leadership
  2. Teamwork
  3. Evidence-based
  4. Communication
  5. Learning
  6. Just culture
  7. Patient-centered

If you’ve been with The Joint Commission and several of the accreditation agencies, you know that leadership has always been first. We kind of take it with a grain of salt, but we can’t anymore. Leadership has to be the most important thing that happens.

The drive needs to start from the top and involve more than executives just putting a stamp on the policy and the plan. Leadership has to own a culture of safety, and when they own it, the team owns it.

Getting real, evidence-based data helps with the communication and the learning of your team members. Leaders have to support a just culture of learning rather than blaming and balance individual accountability with organizational responsibility.

Finally, a culture of safety needs to be patient-centered. You need to include the community and the patients in everything that you do.

9. Management of New Oral Anticoagulants


Tracking adverse events for anticoagulant drugs for has been a part of safety reporting for years, but four new oral anticoagulant medications have been approved since 2014. Here are some strategies and questions you may want to consider when managing these new additions.

Standardized order sets based on individual’s indications

Are you using standardized order sets? Maybe it is time to review to validate if they are evidence-based and individualized.


CDS to alert practitioners to duplication of therapy

Do you have clinical decision systems that can alert your practitioners about duplications or errors in protocols? Having flags on your systems is critical.


Multidisciplinary team plans for reversal of anticoagulant therapy

Consider a multidisciplinary approach to assessing, monitoring and treating for reversal of therapy. Break down the silos that have been around too long.


Reversal agents should be readily accessible

What compliance process measures are you tracking? Are the effective in getting you the information you need to improve? In ActionCue CI, we have a measure for tracking Reversal Agent Usage. This is an example of error prevention, analyze and assess where the problems are and fix it.


Collection and analysis of events

Collection and analysis of events is what ActionCue CI does well. Let’s go one step further and take action for improvement.


8. Inadequate Management of Behavioral Health Issues in Non-Behavioral Health Settings


Behavioral health hospitals have been doing this for quite some time, but healthcare hospitals are not as good at recognizing a patient’s behavioral health. It’s essential that you start preventatively tracking behavior before it becomes a norm in the environment. When you do that, you get outcomes that you can analyze and prioritize.

Your tracking system should include clinical as well as unsafe environment special events. ActionCue CI gives users a Behavior event category training staff to be competent on identifying, reporting and resolving issues. One event ActionCue CI tracks is rapid response. Train your staff now to be competent on identifying those issues, early signs and behavior cues. Don’t wait until it gets to be serious.

7. Opioid Administration and Monitoring in Acute Care  


This is a serious situation in this country, not just in acute care. You want to track all of your rescue drug and narcotics usage. But how? Are you looking at narcotic adverse drug events? What’s your reversal drug rate? How many times have you had to use your reversal drugs and for what reasons?

You also need to look at your protocols. What are your protocols for rapid response? Do you have the right equipment? Do you need to buy new equipment? You need to be looking at your medical equipment to make sure it’s up to standards.

Finally, you need to look at the nursing process as you’re investigating events and recommending solutions. You need to go back to look at the basic process so that you’re not forgetting anything as you’re assessing.

6.  Patient Identification


Many healthcare settings have stopped tracking patient identification errors. But when you consider that out of 7, 613 events, 9% resulted in patient injury, including two deaths, this is still a serious issue that needs to be addressed from the leadership down.

Leaders can start by fully supporting patient identification initiatives by prioritizing the issue, engaging clinical and nonclinical staff, and asking staff to identify barriers to safe identification practices.

Go back to tracking your patient identification and include in your policies and procedures the contributing causes to the problems the team identified from the event reports. Make this something in your investigation process that your staff are looking at. Your end users are your best value. They’re the ones who see everything that’s going on and who know what needs to be fixed. Give them the opportunity to be involved.

Imagine if you had a button in your event that would automatically create a performance improvement action team. Let’s say the safety risk manager sees that this is the fifth time he’s seen patient identification as a problem. With the click of a button, he decides to create a team. The team works from within the application which serves as a working platform so they can collaborate. Reports are generated automatically, which include the month-to-month analysis and compares agencies and experts that you want to compare yourself to.

The best thing, however, is that you also get the action plan attached to a scorecard report and run chart in ActionCue CI. This is created in real time so you don’t have to wait. It’s all about efficiency. Why should a quality manager go to a committee meeting, decide that she needs a team and spend 2-4 weeks getting one together? She should be able to have the information she needs at her fingertips that she can drill down into.  

Focus on the Process


It’s difficult and unsustainable to cram everyone’s head so full of education to the degree that they will continually act in a heroic manner to overcome flaws or deficits in institutional processes and leadership. Until we focus on optimizing the work itself with best process innovations, technology, leadership, goals and respect, organizations will “keep on getting what they’ve always got,” which is not the culture of safety we all need.

In part 2 of this article, we will review the remaining top 5 patient safety concerns for healthcare organizations as they apply to our focus on building a culture of safety.


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About the Author Faris Islam


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