- Email: [email protected]
Leadership, Accountability, and Patient Safety
JOGNN
LETTER
Leadership, Accountability, and Patient Safety Jennifer L. Moller
Correspondence Jennifer L. Moller, MSN, RNC-OB, C-EFM, Women’s Health Services Hartford Hospital 80 Seymour Street Hartford, CT 06109. [email protected] Jennifer L. Moller is the Perinatal Safety Coordinator for Women’s Health Services, Hartford Hospital, Hartford, CT.
To the Editor, Nancy Lowe’s professional reflections regarding the relationship between nursing leadership, accountability, and the current state of patient safety raise important questions for nurse leaders to consider. As the report “To Err is Human-To Delay is Deadly” (Safe Patient Project, 2009) reminds us, there are still obstacles in our quest for patient safety. One such obstacle is the lack of accountability and transparency in medical error reporting. Near-miss and adverse-event reporting are central to the task of mitigating medical error and are characterized as hallmarks of high-reliability organizations (Knox & Simpson, 2010). But compliance with error reporting creates a dilemma because it carries an expectation that health care providers will come forward and openly admit to having made mistakes. Selfdisclosure exposes offenders to scrutiny and condemnation from peers while provoking disciplinary action from institutions, managers, local regulatory bodies, and the legal system (Dekker, 2012). Faced with these consequences, individuals who make mistakes will most likely refrain from reporting errors, particularly when there is no resultant patient harm. Such lack of accountability robs the medical community of opportunities to identify system failures, which leaves subsequent patients vulnerable to the same threats.
The author reports no conflict of interest or relevant financial relationships.
506
For a true patient safety culture to exist, the medical community must transition from a culture that blames the individual caregiver to a just culture (Marx, 2001). In a just culture there is an understanding and acceptance that errors and harm are most often the result of an interplay between multiple human factors and system failures rather than a single, purposeful act of caregiver negligence (Reason, 1997). Nurse leaders are poised to play a pivotal role in bringing about this change by promoting professional environments in which nurses and other caregiver feel safe reporting er-
rors but are held accountable in a system in which the intricacies and fallibility of human performance are acknowledged. The following key principles of a just culture described by Marx are important for nurse leaders to embrace and model:
r r r
r
Systems should be designed to decrease the likelihood of human error while enabling caregivers to make safe decisions. Incidents and near misses are viewed as learning opportunities for the individual and the organization. Human error and behavioral choices should be managed with counseling and coaching. Punitive actions should be reserved for only those behaviors that reflect recklessness and blatant disregard for safety policies and practices. Institutions must build open, fair cultures that strike a balance between a punitive and blame-free culture.
The just culture model should be integrated into the nursing leadership model through education, collaboration, and endorsement. Academic institutions and medical organizations must offer nurse leaders learning opportunities that focus on just culture ideology. Curricula should include courses and seminars that explore human error management, human factors theory, cognitive behavioral theory, and the process of root cause analysis. Nurse leaders must then seek out collaborative alliances with safety advocates from other highreliability organizations such as the aviation industry, which has had well-documented success in improving operational safety after incorporating the just culture model into its error-reporting policies (NASA Aviation Safety Reporting System, 2012). Professional nursing organizations such as the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) must endorse just culture ideology by issuing supportive formal position statements similar to those of the American Nurses Association (2010), the American College
C 2013 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
http://jognn.awhonn.org
LETTER
Moller, J. L.
of Obstetricians and Gynecologists (2009), and the Joint Commission (2009).
no. 447. Obstetrics & Gynecology, 114(6), 1424–1427. doi:10.1097/AOG.0b013e3181c6f90e American Nurses Association. (2010). Just culture. Position state-
Dr. Lowe asked whether personal, team, unit, and institutional accountability will finally result in a safer and more effective health care system. It is important to acknowledge that accountability will only strengthen the health care system when it is cultivated within the framework of a just culture model. Medical errors will never be completely eradicated because human beings are fallible. But if we can foster environments that allow caregivers to feel safe to report their mistakes, individual and collective accountability will have greater visibility, and the public’s trust in the health care system will be restored.
ment. Retrieved from http://www.justculture.org/downloads/ ana_just_culture.pdf Dekker, S. (2012). Just culture: Balancing safety and accountability. Hampshire, UK: Ashgate Publishing. Joint Commission. (2009). Sentinel event alert: Issue 43: Leadership committed to safety. Retrieved from http://www. jointcommission.org/sentinel_event_alert_issue_43_leadership_ committed_to_safety/ Knox, G. E., & Simpson, K. R. (2010). Perinatal high reliability. American Journal of Obstetrics and Gynecology, 204(5), 373–377. doi:10.1016/j.ajog.2010.10.900 Marx, D. (2001). Patient safety and the “just culture”: A primer for health care executives. New York, NY: Columbia University. NASA Aviation Safety Reporting System. (2012). ASRS program briefing. Moffett Field, CA: Author. Retrieved from http://asrs.arc.nasa.gov/contact.php
Jennifer L. Moller, MSN, RNC-OB, C-EFM
Reason, J. (1997). Managing the risks of organizational accidents. Hants, UK: Ashgate Publishing. Safe Patient Project. (2009). To err is human – To delay is
REFERENCES
deadly.
American College of Obstetricians and Gynecologists. (2009). Pa-
http://safepatientproject.org/safepatientproject.org/pdf/
tient safety in obstetrics and gynecology. Committee opinion
JOGNN 2013; Vol. 42, Issue 5
Austin,
TX:
Consumers
Union.
Retrieved
from
safepatientproject.org-ToDelayIsDeadly.pdf
507
LETTER
Leadership, Accountability, and Patient Safety Jennifer L. Moller
Correspondence Jennifer L. Moller, MSN, RNC-OB, C-EFM, Women’s Health Services Hartford Hospital 80 Seymour Street Hartford, CT 06109. [email protected] Jennifer L. Moller is the Perinatal Safety Coordinator for Women’s Health Services, Hartford Hospital, Hartford, CT.
To the Editor, Nancy Lowe’s professional reflections regarding the relationship between nursing leadership, accountability, and the current state of patient safety raise important questions for nurse leaders to consider. As the report “To Err is Human-To Delay is Deadly” (Safe Patient Project, 2009) reminds us, there are still obstacles in our quest for patient safety. One such obstacle is the lack of accountability and transparency in medical error reporting. Near-miss and adverse-event reporting are central to the task of mitigating medical error and are characterized as hallmarks of high-reliability organizations (Knox & Simpson, 2010). But compliance with error reporting creates a dilemma because it carries an expectation that health care providers will come forward and openly admit to having made mistakes. Selfdisclosure exposes offenders to scrutiny and condemnation from peers while provoking disciplinary action from institutions, managers, local regulatory bodies, and the legal system (Dekker, 2012). Faced with these consequences, individuals who make mistakes will most likely refrain from reporting errors, particularly when there is no resultant patient harm. Such lack of accountability robs the medical community of opportunities to identify system failures, which leaves subsequent patients vulnerable to the same threats.
The author reports no conflict of interest or relevant financial relationships.
506
For a true patient safety culture to exist, the medical community must transition from a culture that blames the individual caregiver to a just culture (Marx, 2001). In a just culture there is an understanding and acceptance that errors and harm are most often the result of an interplay between multiple human factors and system failures rather than a single, purposeful act of caregiver negligence (Reason, 1997). Nurse leaders are poised to play a pivotal role in bringing about this change by promoting professional environments in which nurses and other caregiver feel safe reporting er-
rors but are held accountable in a system in which the intricacies and fallibility of human performance are acknowledged. The following key principles of a just culture described by Marx are important for nurse leaders to embrace and model:
r r r
r
Systems should be designed to decrease the likelihood of human error while enabling caregivers to make safe decisions. Incidents and near misses are viewed as learning opportunities for the individual and the organization. Human error and behavioral choices should be managed with counseling and coaching. Punitive actions should be reserved for only those behaviors that reflect recklessness and blatant disregard for safety policies and practices. Institutions must build open, fair cultures that strike a balance between a punitive and blame-free culture.
The just culture model should be integrated into the nursing leadership model through education, collaboration, and endorsement. Academic institutions and medical organizations must offer nurse leaders learning opportunities that focus on just culture ideology. Curricula should include courses and seminars that explore human error management, human factors theory, cognitive behavioral theory, and the process of root cause analysis. Nurse leaders must then seek out collaborative alliances with safety advocates from other highreliability organizations such as the aviation industry, which has had well-documented success in improving operational safety after incorporating the just culture model into its error-reporting policies (NASA Aviation Safety Reporting System, 2012). Professional nursing organizations such as the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) must endorse just culture ideology by issuing supportive formal position statements similar to those of the American Nurses Association (2010), the American College
C 2013 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
http://jognn.awhonn.org
LETTER
Moller, J. L.
of Obstetricians and Gynecologists (2009), and the Joint Commission (2009).
no. 447. Obstetrics & Gynecology, 114(6), 1424–1427. doi:10.1097/AOG.0b013e3181c6f90e American Nurses Association. (2010). Just culture. Position state-
Dr. Lowe asked whether personal, team, unit, and institutional accountability will finally result in a safer and more effective health care system. It is important to acknowledge that accountability will only strengthen the health care system when it is cultivated within the framework of a just culture model. Medical errors will never be completely eradicated because human beings are fallible. But if we can foster environments that allow caregivers to feel safe to report their mistakes, individual and collective accountability will have greater visibility, and the public’s trust in the health care system will be restored.
ment. Retrieved from http://www.justculture.org/downloads/ ana_just_culture.pdf Dekker, S. (2012). Just culture: Balancing safety and accountability. Hampshire, UK: Ashgate Publishing. Joint Commission. (2009). Sentinel event alert: Issue 43: Leadership committed to safety. Retrieved from http://www. jointcommission.org/sentinel_event_alert_issue_43_leadership_ committed_to_safety/ Knox, G. E., & Simpson, K. R. (2010). Perinatal high reliability. American Journal of Obstetrics and Gynecology, 204(5), 373–377. doi:10.1016/j.ajog.2010.10.900 Marx, D. (2001). Patient safety and the “just culture”: A primer for health care executives. New York, NY: Columbia University. NASA Aviation Safety Reporting System. (2012). ASRS program briefing. Moffett Field, CA: Author. Retrieved from http://asrs.arc.nasa.gov/contact.php
Jennifer L. Moller, MSN, RNC-OB, C-EFM
Reason, J. (1997). Managing the risks of organizational accidents. Hants, UK: Ashgate Publishing. Safe Patient Project. (2009). To err is human – To delay is
REFERENCES
deadly.
American College of Obstetricians and Gynecologists. (2009). Pa-
http://safepatientproject.org/safepatientproject.org/pdf/
tient safety in obstetrics and gynecology. Committee opinion
JOGNN 2013; Vol. 42, Issue 5
Austin,
TX:
Consumers
Union.
Retrieved
from
safepatientproject.org-ToDelayIsDeadly.pdf
507