**3. Gradual and sustainable culture change**

further accelerating our understanding of various "gaps in safety" and corresponding "failure modes" [10–12]. It is hoped that these incremental steps will collectively help reduce both the frequency and impact of medical errors and hopefully lead to better mitigation strategies and the ultimate attainment of the elusive "zero incidence" goal [13]. Some examples of early successes include the growing evidence that adverse outcomes are becoming less common across different areas of care, likely due to a combination of better training and more effective processes and procedures becoming integrated into existing safety systems [11, 14–16]. Concepts such as "failure to rescue" and "never-events" serve to focus teams on minimizing relatively infrequent, but often catastrophic events (e.g., hospital acquired infections; delays in therapy for critical diagnoses such as stroke, sepsis, acute respiratory failure, or acute myocardial infarction) [17–20]. Again, the ultimate goal is to simultaneously achieve 100% readi-

The evolving role of public reporting of quality and safety data, including various clinical metrics and outcomes, will provide a powerful stimulus for developing processes and systems that will make patient care both safer and more efficient [21, 22]. However, without proper organizational and individual context, exclusive attention to such metrics will not inherently result in better or safer care [23–25]. For example, a study looking at 28 strategies to improve "door-to-balloon time" (a commonly utilized quality metric in cardiovascular medicine) across 365 hospitals demonstrated that despite several strategies being associated with substantial reductions in "door-to-balloon time," only a minority of institutions was actually utilizing these proven approaches [26]. It is therefore critically important to evaluate PS systems in a comprehensive and multifactorial fashion, maintaining open and constructive stance on exploring "what is going right", "what has gone wrong", and "what might go

The success of patient safety initiatives and corresponding systemic implementations is heavily dependent on the thorough understanding of the overall framework within which structures, processes, and outcomes dynamically interact in health-care [27]. With that knowledge, it is important to integrate key processes in order to increase organizational efficiency and effectiveness. Examples of successful interventions that span across different domains of the health-care matrix include checklists, standardized handoff protocols, intense analyses/sentinel event reviews, and institutional safety and quality improvement projects [5, 7, 28].

Using specialized processes, such as the plan-do-check-act (PDCA) quality improvement cycle, modern PS protocols and approaches continue to evolve and become increasingly more optimized [29]. Organizations must continue to transform PS systems into more horizontal, cross-disciplinary platforms that function in a nonpunitive, fair, respectful, and inclusive fashion [30, 31]. Determinations regarding the importance and relevance of any constructive input should not be based on hierarchical considerations, but rather on the informational content being communicated [28, 32, 33]. The end goal is to hard-wire quality and safety improvement

ness and 0% incidence for any such occurrences.

2 Vignettes in Patient Safety - Volume 4

**2. Integrative approach to patient safety**

wrong."

Patient safety culture depends heavily on institutional ability to create an environment that welcomes honest disclosure and constructive, nonjudgmental feedback [43]. It has been shown that more positive PS culture correlates with fewer adverse health-care events [44]. A change in culture is no easy feat, but it is instrumental in the development of an environment that does not penalize human error (**Figure 1**). It has been suggested that although humans certainly contribute to adverse events, faulty organizational systems are more likely to be at the root of many of these errors [45]. This suggests that a more fundamental change is needed to affect the safety and quality of care delivered within the health-care system. It has been pointed out that institutions fully committed to a culture of patient safety have seen reductions in medical errors [45]. This involves integration of "error management strategies" to analyze the causes of error and instituting mechanisms of prevention [46]. Buy-in from administration as well as other leadership is integral to the process of adoption of a patient safety culture. Without engagement from leadership, it will be difficult to transform existing organizational "patterns and habits". Hospital leadership must set PS as a priority, even

**4. The challenge of habits: The art of learning and unlearning**

**5. The importance of anonymous event reporting in maintaining** 

In many countries, incident reporting in health-care has become a well-accepted method of improving overall patient safety [56]. Strategic collection of adverse events and "near misses" from across our care delivery platforms allows safety specialists to efficiently analyze each event, identify potential underlying factors, and implement action plans based on this knowledge to help reduce systemic risk levels in the future [5, 7]. However, in the United States, medical errors continue to be significantly underreported, as exemplified in a study of over 1600 hospitals which concluded that substantial proportion of facilities lacked adequate event

The overarching question then becomes, which components comprise a thorough, accurate, and effective reporting system design within health-care? Specifically, published studies identify several factors that are essential to constructive "incident reporting". These factors include: staff willingness to report incidents, removal of barriers to incident reporting, the overall culture surrounding reporting, classifying and monitoring the number of incidents reported, taxonomies for various types of patient safety events, and the constitution of incident reporting systems [58–60]. Moreover, one of the greatest challenges that exist with regards to the incident reporting process is determining a way to create a "no blame" culture

and balancing team accountability versus individual responsibility [58–60].

pursuit of mastery naturally follows [55].

**patient safety**

reporting systems [57].

A culture of safety represents a complex system of behaviors and hardwired procedures, designed to synergistically create a safe, reliable and efficient, high-quality clinical environment [51, 52]. The creation of such a sophisticated institutional cultural milieu requires all stakeholders to commit to unprecedented amounts of commitment and flexibility [51–53]. In many cases, the organizational transition process can span years and require the replacement of "bad habits" with positive behaviors—a difficult undertaking given the inherent human tendency to resist change when having to "unlearn things" [54]. So how do we change bad habits, motivate people to "do the right thing", and sustainably instill safe and productive behaviors? To motivate individuals, we must first recognize why and how people are influenced. In his book *Drive: The Surprising Truth About What Motivates Us*, Daniel Pink points out that historically our good behavior has been incentivized with rewards and our bad behaviors reprimanded [55]. This carries the unintended consequence of undermining an individual's motivation. He suggests humans have a strong inner-drive to be autonomous, self-determined, and connected. We all seek the trifecta of attaining autonomy, mastery, and purpose in both our work and our lives. Upon achieving these elements, people will take on greater responsibility, believing they are effecting positive change. With this sense of autonomy and purpose comes increased self-esteem, confidence, and motivation to go beyond what is merely required. The

Introductory Chapter: Patient Safety is the Cornerstone of Modern Health-Care Delivery Systems

http://dx.doi.org/10.5772/intechopen.83842

5

**Figure 1.** The relationship between institutional culture of safety and improved patient outcomes involves the presence of key foundational factors coupled with effective adoption of patient safety initiatives and the fostering of constructive feedback.

placing it above clinical productivity [45]. Institutional leaders are instrumental in creating a culture of honest disclosure, support, and constructive feedback. When errors occur, root cause analysis ensues to understand which specific systemic factors may have been contributory. The natural inclination to point fingers and blame a specific person or persons for making a mistake is discouraged. Adjustments to the system are then implemented to prevent the reoccurrence of the specific error in question. This includes sitting down with the individuals involved and addressing what went wrong and what needs to be done to prevent similar errors in the future. An action plan may include instituting failsafe mechanisms within the system to prevent performance of certain harmful actions. Development of a patient safety culture depends heavily on organizational structure and priorities, transformational leadership that can trickle down to other stakeholders as well as effective communication amongst all parties involved. Taken collectively, all of the above interventions act synergistically to help create and reinforce a culture of patient safety.

Once safe systems are in place, their preservation becomes critical. In addition, the long-term goal then transitions into permanent culture change that hopefully becomes a source of pride for both employees and the organization [7, 28]. Once a culture of safety is achieved, other aspects of institutional change can occur, including alignment of goals, especially between clinicians and administration. By association, one can also expect improved employee morale, enhanced quality of care, and other positive manifestations of a well-functioning organization. As a word of caution, the same can also occur "in reverse," where negative influences can insidiously and gradually erode various positive elements and influences within the institutional culture [7, 47–50].
