Promoting a Culture of Patient Safety

Healthtrust Members Make Error Reduction a Priority

Healthcare-associated infections (HAIs) strike 1 in 25 hospitalized patients annually, killing an estimated 75,000 of them, according to the federal Office of Disease Prevention and Health Promotion. Across developed countries, the World Health Organization estimates that 1 in 10 inpatients will be harmed due to safety errors. HAIs also lead to billions of dollars in additional medical treatment and the potential loss of reimbursement for healthcare facilities.

For all these reasons, it is critical that hospitals improve patient safety. One of the first steps toward that goal is creating a culture of safety within the facility. This culture is built by relentlessly pursuing safety and error-reduction from a variety of angles. Building culture isn’t an initiative; it’s a value that underlies many initiatives, enacted over many years.

Verifying Medications

At Hospital Corporation of America (HCA), patient safety has long been a priority. One example is its adoption of barcode verification technology 12 years ago—long before it was a requirement.

“Our barcode verification systems help us add reliability to what we do,” says Jane Englebright, Ph.D., RN, CENP, FAAN, and chief nurse executive, patient safety officer and senior vice president at HCA. “We use them for the administration of medications and blood products and positive patient identification.”

In the early days of implementing one barcode verification system, Englebright was called by a nurse to the ICU. “A patient was having active seizures, so the nurse was about to give some medication, which the computer was saying was the wrong medication. The nurse thought there was something wrong with the computer,” Englebright says.

It turned out the nurse did have the right medication, but not the right type. The patient needed the quick-acting rather than the sustained release formulation.

“For a patient who is actively seizing, that medication wouldn’t have helped stop the seizures, and it could have led to being moved to a second line of drug therapy, or an extra day in the ICU,” Englebright says. “It’s an easy human error to make.”

Choosing the wrong form of the correct medication is the most common type of medication error detected by barcode verification technology, Englebright explains. Other identified errors include incorrect dosing and drug allergies.

Reducing Catheter-associated Urinary Tract Infections

Research Medical Center (RMC) in Kansas City, Missouri, likewise has become a leader in patient safety. This is due largely to the efforts of Gayle Whitmore, RN, infection prevention/occupational health nurse, one of 33 fellows nationwide in the Health Research & Educational Trust’s Project Protect: Infection Prevention Fellowship. The goal of the fellowship is to reduce the number of catheter-associated urinary tract infections.


Research and use any technology that can help eliminate human error and prevent harm, such as needleless IVs, safety needles and barcode verification systems.

Make sure safety policies are in place for such initiatives as patient safety rounding and patient mobilization activities.

Compile pre-procedure verification checklists.

Develop best practices with regard to reducing device-associated infections.

Emphasize staff education, including injury prevention and proper use of new equipment, especially in areas where staff turnover is high.

Each of the 33 fellows has a specific project, and Whitmore’s focuses on the intensive care unit at RMC because of its high catheter usage. In the past, an ICU patient who had just undergone cardiac bypass surgery would automatically have a catheter for two to three days after the procedure. Since Whitmore began making daily rounds with the ICU nurses, they have been assessing each patient individually to decide if a catheter is necessary.

“It really was a change in their culture,” she says. “The thought had been, ‘They’re an intensive care patient, so of course they need a urinary catheter.’ But that isn’t the case. Being able to speak with all of the nurses helped change their perception. The nurses now individually assess patients whether I’m there or not.”

RMC also developed a nurse-driven protocol for dealing with catheters, thanks to Whitmore’s project.

“The protocol empowers nurses—without having to call the doctor—to take out the catheter if it’s not necessary or not following best recommended practices,” Whitmore says. “The physician may not have even realized the catheter was there.”

Yet another result of Whitmore’s project has been finding alternatives to indwelling catheters. “We were able to change to a new external catheter device because the previous product wasn’t working as well for the male patients,” she says.

Bringing Close Calls to Light

HCA has started using close-call reporting to help bolster its patient safety culture and procedures. Reporting and investigating close calls—defined as safety events that did not impact the patient—help hospitals narrow down where there might be a breakdown in communication or protocol.

Preventing close calls often mean working back upstream to locate the gaps or lapses in a process, then making improvements and corrections to prevent patient harm.

Clear communication, accountability and transparency are also key, according to a December 2013 report in The Joint Commission Journal on Quality and Patient Safety. Staff members should be encouraged to report all errors with a collective desire to find where and why they occurred, creating a trusting, positive environment of learning and improving systems, rather than blame, negativity and cover-ups.

Focusing on Hand Hygiene, New Initiatives

An intensive focus on hand hygiene since last year has led to significant patient safety improvements at RMC, according to Carolyn Gasser, RN, CIC, MPH, infection control manager.

“We’ve had to promote that you must redo your hand hygiene regimen after you’ve done certain tasks and before you do certain procedures. That’s part of a culture change, too.” — Carolyn Gasser, RN, CIC, MPH, infection control manager

“We found we needed to reemphasize the proper way to conduct hand hygiene within the patient’s room,” Gasser says. “We’ve had to promote that you must redo your hand hygiene regimen after you’ve done certain tasks and before you do certain procedures. That’s part of a culture change, too.”

Other initiatives and procedures, such as flu shots for patients and staff; using needleless IVs, safety needles and safe surgical checklists; and eliminating devices that might cause harm to the patient, such as leather restraints, help foster a culture of patient safety, Englebright says.

Designing a patient safety rounding initiative is another way to place a high organizational priority on patient safety, Englebright notes. In programs such as ones at the Dana Farber Cancer Institute in Boston, risk managers, chief nursing officers and others round in clinical areas to engage and interview staff and patients to identify actual and potential safety problems.

“A culture of safety means staff is preoccupied with safety,” Gasser says. “We must make sure that care environments are as free from harm as possible, and that our care activities incorporate safety principles. Doing no harm needs top-of-mind awareness.”

For patient safety resources and tools, visit the Agency for Healthcare Research and Quality (AHRQ).

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