Culture eats strategy for breakfast

In human error, Patient Safety, Safety climate on March 22, 2011 at 6:02 pm

The 2011 patient safety culture report is out from the AHRQ detailing the results from the survey of patient safety culture in over 1000 hospitals with almost half a million responders. There is some good news and some very concerning news. On the bright side, teamwork and supervisor attention to patient safety received high marks with 75-80% positive responses. Very concerning however are the two lowest scores: handoffs and hospital response to error.

The positive responses to the perception of safe handoffs came in at only 45% and the perception of a non-punitive response to error weighed in at 44%. Of particular concern, as expressed many times on this blog, is the perception of 56% of respondents that response to error is punitive! This perception has not improved AT ALL since the 2007 survey when data was collected from 382 hospitals.
For the New England region only this response to error survey item elicited a positive response in a paltry, scary 38% of respondents. 62% of those working in hospitals in New England perceive that there is a punitive approach to error!
What does this mean?
A culture in which staff perceive that they will be punished for making errors, creates secrecy and a reluctance to report incidents. This can lead to great patient harm. When you blame by the bad apple theory (the error involved a bad clinician) and punish the “bad apples,” the system goes unfixed making the next patient every bit as vulnerable as the one who was harmed by the “bad apple.” Unsafe conditions and near misses go under-reported creating a significant deficit for senior leaders who are trying to improve safety and quality for their organizations. As a senior leader, even if your policy is non-punitive, if the staff believe it is punitive their behavior will be risky.

To move away from a culture of blame, I suggest going to the Just Culture community website linked on this blog or reading “Behind Human Error” (2010) by Woods, Dekker, et al.

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