Jane Barnsteiner, PhD, RN, FAAN
Although a healthcare culture of safety has been a practice priority for many years, there has been less attention to incorporating culture of safety content into the education of healthcare professionals. Students need to become knowledgeable about system vulnerabilities and understand how knowledge, skills, and attitudes promoting utilization of safety science will lead to safer care for patients and families. Learning about both patient safety and system vulnerabilities needs to begin in pre-licensure programs and become an integral part of learning in all phases of nursing education and practice. In this article the author will begin by reviewing the essential elements of a culture of safety and considering what students need to know about a culture of safety. She will describe activities that promote safety, high reliability organizations, and external drivers of safety, and conclude by offering strategies for integrating a culture of safety into the curriculum.
Citation: Barnsteiner, J., (September 30, 2011) "Teaching the Culture of Safety" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 3, Manuscript 5.
Key words: culture of safety, safety culture, culture of safety education, teaching culture of safety, safety competencies, culture of safety elements, activities to promote safety
Although the goal of a culture of safety is to lessen harm to patients and providers through both system effectiveness and individual performance (Cronenwett et al., 2007), numerous threats to patient safety remain and errors occur at all interfaces of care delivery. Common obstacles to a safe system include complex and risk-prone systems that produce unintended consequences; lack of comprehensive verbal, written, and electronic communication systems; tolerance of stylistic practices and lack of standardization; fear of punishment which inhibits reporting; and lack of ownership for patient safety. Nurses need to be knowledgeable about system vulnerabilities and understand how knowledge, skills, and attitudes promoting the utilization of safety science will lead to higher quality care for patients and families (Finkelman & Kenner, 2009).
It is important to recognize that errors can take place across the healthcare system. Latent failures, sometimes called the ‘blunt’ end, arise from decisions that affect organizational policies, procedures, and allocation of resources. One example would be the purchasing department’s ordering a new type of intravenous pump without input from front-line clinicians. Active failures occur at the interface of contact with the patient, for example during medication administration. These errors are sometimes referred to as the ‘sharp’ end. Organizational system failures, or indirect failures, are related to management, organizational culture, protocols/processes, transferring of knowledge, and external factors, for example decisions regarding staffing and scheduling. Technical failures are the indirect failure of facilities or external resources (Reason, 2000).
The Institute of Medicine (IOM) has worked to move our emphasis from addressing errors to promoting safety through widespread system changes. The Institute of Medicine (IOM) has worked to move our emphasis from addressing errors to promoting safety through widespread system changes. The message in To Err is Human was to prevent, recognize, and mitigate harm from error, defined as, the “failure of a planned action to be completed as intended ... or the use of a wrong plan to achieve an aim" (Kohn, Corrigan, Donaldson, 2000, p.28). Developing a culture of safety in learning organizations, understanding the limits of human factors, and appreciating the reasons for comprehensive reporting mechanisms are all essential components in the preparation of nurses to be participants in 21st Century healthcare (Berwick, Calkins, McCannon, & Hackbarth, 2006). Learning about both patient safety as a fundamental quality of patient care and system vulnerabilities needs to begin in pre-licensure programs and be an integral part of learning in all phases of nursing education and practice (Cronenwett et al., 2007, Cronenwett et al., 2009).
In this article I will begin by reviewing the essential elements of a culture of safety and considering what students need to know about a culture of safety. Then I will describe activities that promote safety, high reliability organizations, and external drivers of safety, and conclude by offering strategies for integrating a culture of safety into the curriculum.
Essential Elements of a Culture of Safety
A safety culture requires strong, committed leadership, along with the engagement and empowerment of all employees. Key elements of a culture of safety in an organization include the establishment of safety as an organizational priority, teamwork, patient involvement, openness/transparency, and accountability (Lamb, Studdert, Bohmer, Berwick, & Brennan, 2003). In addition a safety culture is characterized by shared core values and goals, non-punitive responses to adverse events and errors, and promotion of safety through education and training. A safety culture requires strong, committed leadership, along with the engagement and empowerment of all employees.
Today, in a culture of safety, when an adverse event occurs, the focus is on what went wrong, not who caused the problem. In a culture of safety, a balance is achieved between not blaming individuals for errors and not tolerating egregious behavior. This balance is currently referred to as a ‘just culture’ (Mitchell, 2008; Yates et al., 2005). In a just culture the focus is on effective teamwork to accomplish the goal of safe, high-quality patient care. Traditionally, a culture of blame has been pervasive in healthcare. The focus has often been on trying to determine who has been at fault so that the offender can be disciplined. This approach has led to the hiding, rather than the reporting of errors; it is the antithesis of a culture of safety. In contrast a patient safety culture should be non-punitive and emphasize accountability, excellence, honesty, integrity, and mutual respect (Association of periOperative Registered Nurses [AORN], 2006). Today, in a culture of safety, when an adverse event occurs, the focus is on what went wrong, not who caused the problem.
A number of tools are available for assessing the healthcare safety culture within an organization. The most widely used is the Culture of Patient Safety Assessment developed by the Agency for Healthcare Research and Quality (AHRQ), (Sorra, Famolaro, Dyer, Nelson, & Khanna, 2008). Table 1 describes some of these tools.
What Students Need to Know About a Culture of Safety
...patient-centered care, ensures the patient is involved in decision making and understands the plan of care thus preventing errors from occurring. The Quality and Safety Education for Nurses (QSEN) was developed to identify the competencies pre-licensure and graduate students need for safe practice (Cronenwett et al., 2007, Cronenwett et al., 2009). QSEN defines safety as minimize(ing) risk of harm to patients and providers through both system effectiveness and individual performance (Cronenwett, et al., 2007, p. 128). With funding from the Robert Wood Johnson Foundation a group of experts, with consultation and input from multiple accrediting agencies and professional groups, identified the needed safety competencies and disseminated them via publications (Cronenwett et al., 2007; Cronenwett et al., 2009), a website, www.qsen.org/, national forums, and 'train the trainer' workshops for faculty. Didactic, simulation laboratory, and clinical fieldwork teaching strategies have been developed to assist faculty to incorporate a culture of safety into the curriculum.
Traditionally education has focused on the care of individual patients/families, with an understanding of the complexity of care delivery systems being notably absent. The QSEN project places considerable emphasis on helping students understand the complexity of care delivery systems.
Informatics assists clinicians in using information and technology to communicate, access knowledge, and support decision making. Faculty are urged to incorporate the QSEN competencies into their teaching about patient and provider safety. One of the QSEN concepts, patient-centered care, ensures the patient is involved in decision making and understands the plan of care thus preventing errors from occurring. Evidence-based practice guides clinicians in using up-to-date science, in addition to considering clinical expertise and patient values, in designing a plan of care. Teamwork and collaboration assist the healthcare team to communicate and work together effectively, using shared decision making to achieve safe, high quality care. Quality improvement provides for trending and analysis of data to be able to benchmark with comparable organizations and identify system vulnerabilities needing correction. Informatics assists clinicians in using information and technology to communicate, access knowledge, and support decision making. The QSEN project has separated quality and safety into two separate competencies to more comprehensively address the science underlying each of the two and to better describe the knowledge, skills, and attitudes necessary for effective practice.
The QSEN competency for safety lists the knowledge, skills, and attitudes students need to know to practice safely. Table 2 lists the components of the competency, including the elements of a culture of safety, types of healthcare errors, why errors occur, and how to make care safer. This article will focus on the QSEN safety competencies.
Table 2. QSEN Competency: Safety (Cronenwett, et al., Nursing Outlook, 2007, reprinted with permission)
Definition: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as, work-arounds and dangerous abbreviations)
Describe the benefits and limitations of selected safety-enhancing technologies (such as, barcodes, Computer Provider Order Entry, medication pumps, and automatic alerts/alarms)
Discuss effective strategies to reduce reliance on memory
Demonstrate effective use of technology and standardized practices that support safety and quality
Demonstrate effective use of strategies to reduce risk of harm to self or others
Use appropriate strategies to reduce reliance on memory (such as. forcing functions, checklists)
Value the contributions of standardization/reliability to safety
Appreciate the cognitive and physical limits of human performance
Delineate general categories of errors and hazards in care
Describe factors that create a culture of safety (such as, open communication strategies and organizational error reporting systems)
Communicate observations or concerns related to hazards and errors to patients, families and the health care team
Use organizational error reporting systems for near miss and error reporting
Value own role in preventing errors
Describe processes used in understanding causes of error and allocation of responsibility and accountability (such as, root cause analysis and failure mode effects analysis)
Participate appropriately in analyzing errors and designing system improvements
Engage in root cause analysis rather than blaming when errors or near misses occur
Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team
Discuss potential and actual impact of national patient safety resources, initiatives and regulations
Use national patient safety resources for own professional development and to focus attention on safety in care settings
Value relationship between national safety campaigns and implementation in local practices and practice settings
Activities that Promote Safety
The IOM (2001) has identified nine categories that provide opportunities to improve patient safety. Each will be described below. Faculty are encouraged to emphasize the importance of these activities during classroom, laboratory, and clinical teaching.
Incorporating User-Centered Designs
A constraint is a device or process that makes it hard to do the wrong thing, while a forcing function makes it impossible to do the wrong thing... User-centered design approaches visibility, affordance, constraint, and forcing functions. An example of increasing visibility would be a clearly written set of directions on each piece of equipment describing how to return to an earlier step or to change the settings. Affordance indicates how an activity is to be performed, for example marking the correct limb before surgery. A constraint is a device or process that makes it hard to do the wrong thing, while a forcing function makes it impossible to do the wrong thing, such as put the active electrode of the cautery machine into the grounding plate or hook a nasogastric tube to a central line.
Avoiding Reliance on Memory
The use of protocols and checklists both reduce reliance on memory and serve as reminders for the steps to be followed. Standardizing and simplifying processes and procedures decreases the demand on one’s memory, planning, and/or problem-solving processes. The use of protocols and checklists both reduce reliance on memory and serve as reminders for the steps to be followed. Simplifying processes minimizes problem-solving. Establishing the usual dose of a medication as the default in an electronic order entry system and purchasing equipment that is easy to use and maintain are both examples of simplifying processes.
Attending to Work Safety
Work hours, work-loads, staffing ratios, distractions, and interruptions all affect patient safety. In many healthcare settings, realizing that interruptions are a major cause of medication administration errors, nurses have chosen to wear something visually apparent, such as a vest, to indicate they should not be interrupted when they are preparing or administering medications. The use of 'safe zones' and 'sacred spaces' facilitates a safe working environment with minimal distractions for personnel and patients alike.
Avoiding Reliance on Vigilance
Checklists, well-designed alarms, rotating staff, and adequate breaks all decrease the need for remaining vigilant for long periods. The use of well-designed alarms that differentiate a potential emergency, such as a disconnected ventilator needing an immediate response, from a less serious situation, such as an alarm notifying the nurse that an intravenous infusion needs to be adjusted, decrease the need for continuous vigilance. Rotating staff and scheduling staff breaks/meals also decreases the need for remaining vigilant for long periods.
Training for Team Collaboration
The literature is replete with evidence outlining the importance of teamwork and collaboration. Training programs for interprofessional communication and collaboration promote cultures of safety. Skill in effective interprofessional communication and collaboration increase safety, an especially important consideration during transitions in care and hand offs.
Involving Patients in Their Care
Patients and families should be in the center of the care process. It is essential that clinicians include patients and families when making decisions about treatments, offering educational information, and preparing discharge plans. Knowing the plan of care, holding rounds in patient rooms, and having patients/families participate in these rounds all promote patients being at the center and source of control. These practices allow patients to become knowledgeable about their care and correct any misinformation or misunderstandings.
Anticipating the Unexpected
Organizational changes and reorganizations result in new patterns and processes of care. The safe introduction of new processes and technologies requires involvement of front-line users and pilot testing before widespread implementation. Front-line user involvement and pilot testing are essential, for example, when implementing new processes that call for new ways to deliver care, such as changing from a paper record to an electronic healthcare record (EHR). Increasing organizational vigilance with additional staffing and information system resources during the implementation of a new EHR system will promote safer care by preparing for the unexpected breakdowns that may occur when implementing such a large scale change.
Designing for Recovery
Designing and planning for recovery will allow reversal of errors, or make it harder for errors associated with irreversible and critical functions to occur. Errors will occur despite the best of planning. Designing and planning for recovery will allow reversal of errors, or make it harder for errors associated with irreversible and critical functions to occur. When errors do occur stress levels are often high and problem solving skills may be affected. Simulation training promotes the practice of rescues using models and virtual reality. Practicing what to do in the event of an infant abduction or a blood transfusion error and conducting disaster management drills on a regular basis will promote a smooth recovery.
Improving Access to Accurate, Timely Information
Information for decision making needs to be available at the point of care. This includes easy access to drug formularies, evidence-based-practice protocols, patient records, laboratory reports, and medication administration records. Many organizations now have drug formularies and practice protocols available as applications for smart phones, thus providing for just-in-time information availability.
High Reliability Organizations
Organizations that have cultures of safety, foster a learning environment and evidence-based care, promote positive working environments for nurses, and are committed to improving the safety and quality of care are considered to be high reliability organizations (HROs) (Carrol & Rudolph, 2006). HROs are characterized by a safety and quality-centered culture, direct involvement of top and middle leadership, safety and quality efforts that are aligned with the strategic plan, an established infrastructure for safety, and continuous improvement and active engagement of staff across the organization (Bagin et al., 2001; Baker, Day, & Sales, 2006; Shortell et al., 2005). Teaching student to avoid disruptive behavior, enhance their working conditions, avoid workarounds , attend to the human factors in their work setting, coordinate transitions and handoffs, uncover the cause(s) of errors, and disclose errors can help them develop their future work settings into HROs. Each of these activities will be described below.
Workspace designs that promote the flow of patient care and decrease interruptions also decrease the chance of errors and enable organizations to become HROs. Teaching students how to advocate for these working conditions can help them promote cultures of safety. The Joint Commission (TJC, 2008) has identified the pervasive effect of healthcare workers’ disruptive behavior on patient safety. Disruptive behaviors include psychological and physical intimidation, as well as overt and covert activities that intimidate or disrupt care. Disruptive behaviors, such as bullying and abuse, have been documented as having a negative effect on quality of care, patient safety, and nurse retention and job satisfaction (Barnsteiner, 2012; Clarke & Donaldson, 2008; Heath, Johnson, & Blake, 2004). Teaching students early in their careers to avoid and prevent these behaviors can contribute significantly to a culture of patient safety and the development of HROs.
Components of the physical environment that negatively impact working conditions can also produce vulnerabilities for both patients and staff. 'No lift' policies and sufficient patient lifting equipment prevent patient and clinician injuries. Limiting work hours and maintaining adequate staffing prevent fatigue leading unsafe care. Workspace designs that promote the flow of patient care and decrease interruptions also decrease the chance of errors and enable organizations to become HROs. Teaching students how to advocate for these working conditions can help them promote cultures of safety.
Workarounds present patient safety hazards. They occur when clinicians encounter problems or impediments in delivering care and invent a quick way (a workaround) to solve the problem. Nurses engage in workarounds because they are busy and need to get the problem solved quickly. An example would be bypassing the barcoding medication administration procedure because the process has too many steps. This frequently used approach to problem solving leaves system problems untreated and can cause errors. Helping students understand the dangers of workarounds and learn how to report and solve problems at the organizational level can help them to become safer clinicians and their work sites to be highly reliable.
Systems need to be designed to protect against human errors; hence the focus needs to be on meeting the needs of clinicians within the healthcare system. ‘Human factors’ is the science of the interrelationship between humans, the technology they use, and the environment in which they work (Kohn, Corrigan, Donaldson, 2000). Human factors considers our ‘human condition’ or our inability to perform accurately or focus on multiple things at once (Vicente, 2004). Errors result when one is tired, distracted, or interrupted and in turn deviates from safe operating procedures and standards that can be routine yet necessary (Reason, 2000). Recent studies have reported that nurses were interrupted on the average, almost 12 times per hour, 22% of the time while administering medications, and frequently as they performed safety-critical tasks (Brixey, 2010; Trbovich, Prakash, Steward, Trip, & Savage, 2010). Helping students to understand the complex and demanding clinical environments will help them become aware of the components and relationships that influence the safety of care and the reliability of an organization. Systems need to be designed to protect against human errors; hence the focus needs to be on meeting the needs of clinicians within the healthcare system.
The Joint Commission (TJC) (Joint Commission Center, 2010) has a targeted-solutions initiative to improve the handoff process of transferring and accepting patient care responsibilities from one caregiver to another through effective communication. Handoffs of patient care from one nurse to another are common nursing activities (Dayton & Henriksen, 2007; Riesenberg, Leitsch, & Cunningham, 2010; Sexton et al., 2004). Students need to understand that transitions in care and handoffs create vulnerabilities that require special attention. Central to effective handoffs is effective communication. Standardization in the processes of handoffs and face-to-face communication remains key to maintaining patient safety (Dayton, 2007; Friesen, White, & Byers, 2008; Saint, Kaufman, Thompson, Rogers, & Chenoweth, 2005; Welsh, Flanagan, & Ebright, 2010). Handoffs may be facilitated through the use of standardized, change-of-shift reporting checklists. SBAR (situation, background, assessment, and recommendation) descriptions are now frequently used for both interprofessional communication and nurse-to-nurse communication (Barenfinger et al., 2004; Haig, Sutton, & Whittington, 2006; Hanna, Griswold, Leape, & Bates, 2005). Helping students master safe handoffs will enable them to provide safer care for their patients and develop more highly reliable organizations.
Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA) are methods used to examine factors leading to an adverse event or a close call. Faculty can take advantage of the many available resources describing how to conduct RCAs and FMEAs that are found on the Agency for Healthcare Research and Quality (AHRQ) web site. TJC has suggested these processes be used for all sentinel events and that organizations take appropriate actions to eliminate risks associated with sentinel events that have occurred.
A RCA is completed after an adverse event by outlining the sequence of events that led up to the event and identifying factors that contributed to or caused the event. In identifying such ‘root’ causes of an adverse event, the five-‘whys’ approach, which drills down and continues to identify preceding ‘causes,’ is used to keep discussions about causes focused on the system rather than the people. The idea is to uncover the underlying cause(s) of an error by looking at enabling factors that contributed to the event, such as lack of education; latent conditions, e.g., not checking the patient’s ID band; and situational factors, e.g., two patients in the hospital with the same last name, that contributed to or enabled the adverse event (Reiling, Knutzen, & Stoecklein, 2003; Rooney & Vanden Heuvel, 2004).
FMEA is an evaluation technique used to identify and eliminate known and/or potential failures, problems, and errors from a system, design, process, and/or service before they actually occur (Hughes & Blegen, 2008). The goal of a FMEA is to prevent errors by attempting to identify all the ways a process could fail, estimating the probability and consequences of each failure, and taking action to prevent the potential failure from occurring. The simulating of equipment failures has been shown to be a helpful way to hone provider skills, identify equipment vulnerabilities, and evaluate alternative approaches or procedures (Waldrop, Murray, Boulet, & Kraus, 2009).
Nursing faculty are in key positions to help students who may have made even a minor error to recognize both the dangers of becoming a ‘second victim’ and the need to promote their healing by appreciating the complexity of healthcare situations and by seeking counsel from managers and human resources departments. Accountability to patients and families is a hallmark of a culture of safety. Disclosure of errors to patients is linked to patient safety efforts and is mandated by many state patient-safety requirements. It involves both communicating information about the error and addressing the patient's emotions. HROs in healthcare have in place policies, processes, and training directed toward disclosing healthcare errors and significant near misses to patients and their families. It is important that students understand the disclosure process and develop disclosure communication skills related to the delivery of difficult news.
Healthcare professionals often report feeling worried, guilty, and depressed following serious errors, as well as concern for patient safety and fearful of disciplinary actions (Rassin, Kanti, & Silner, 2005; Rossheim, 2009; Wolf, 2005). They also are aware of their direct responsibility for errors and may blame themselves for serious-outcome errors. Wu (2000) coined the phrase ‘second victim’ to describe the impact of errors on professionals. Rather than allowing these 'victims' to suffer alone after an adverse event, we need to develop systems to assist clinicians to understand the event, and the often complex circumstances surrounding the event, and to promote their healing, as well as to improve the healthcare system (Denham, 2007; White, Waterman, McCotter, Boyle, & Gallagher, 2008). Nursing faculty are in key positions to help students who may have made even a minor error to recognize both the dangers of becoming a ‘second victim’ and the need to promote their healing by appreciating the complexity of healthcare situations and by seeking counsel from managers and human resources departments.
External Drivers of Safety
Regulation, legislation, accrediting organizations, professional organizations, and public engagement can impact the safety and quality of nursing care and healthcare. It is important that students have a beginning awareness of these external, patient safety-regulators. Many states, for example Pennsylvania and Texas, now have error-reporting laws. Accrediting organizations, such as TJC, influence patient safety with explicit standards including the National Patient Safety Goals and handoff communication guidelines. The Centers for Medicare and Medicaid Services (CMS) are linking the performance on quality indicators, such as central line infections, with hospital payment. The National Council of State Boards of Nursing (NCSBN) Practice Breakdown Advisory Panel (PBAP) has been established to study nursing practice breakdown, identify common themes related to adverse events, and recommend strategies to correct unsafe practices (NCSBN, 2010). It is expected that this work will shift the focus of State Boards of Nursing from punishment to prevention and correction. The American Nurses Association has widely publicized standards related to prevention of workplace injuries due to needle sticks and patient lifting; and the American Association of Critical-Care Nurses has promulgated standards for establishing and sustaining healthy work environments (AACN, 2005). All of these regulations, standards, and guidelines are impacting the environments in which nurses work (Antonovsky, Smith, & Silver, 2000; Elnitsky, Nichols, & Palmer, 1997; Evans et al., 2006).
New norms also drive patient safety. Transparency is now a critical factor in a culture of safety. It implies an acceptance of human elements in error and a means of reporting any error, near miss, or identified potential for error. Many errors go unreported by healthcare workers out of fear that self-reporting will result in repercussions. Openness is important so that errors and potential problems are exposed and addressed before they endanger others. Faculty are encouraged to establish cultures of openness in their classrooms and clinical settings.
Students should also be encouraged to report near misses and understand how aggregate data from near-miss analyses is used to direct attention to critical safety issues. Another recent recognition is that near-misses are more common than adverse events and provide valuable information regarding weaknesses in systems that predispose to adverse events (Bagin et al., 2001). Students should also be encouraged to report near misses and understand how aggregate data from near-miss analyses is used to direct attention to critical safety issues. Discussions of near-misses usually do not generate the defensive reaction often associated with discussion of adverse events. The presence of leadership committed to patient safety; elimination of a punitive culture; institutionalization of a culture of safety; reporting of near misses; providing of timely feedback and follow-up actions; improvements that avert future errors; and a multidisciplinary approach to reporting all serve to increase error reporting (Lawton & Parker, 2002; Nuckols, Bell, Liu, Paddock, & Hilborne, 2007; Thurman, 2001). Faculty are encouraged to provide such environments for their students.
Integrating a Culture of Safety into the Curriculum
Sherwood (2011) recently described worldwide initiatives for integrating quality and safety science into both nursing education and practice. These initiatives include the development of patient safety educational standards, incorporation of safety competencies into the ‘essentials documents’ of accrediting organizations, and curriculum mapping for spreading the competencies across the curriculum.
However, nurse educators are not able to teach what they don’t know and many nurse educators have had limited exposure to the Institute of Medicine reports and/or the QSEN competencies. With funding from the Robert Wood Johnson Foundation, the American Association of Colleges of Nursing has held a series of regional institutes across the country using a train-the-trainer faculty development model to provide content on patient safety and to assist educators in transforming their curriculum so that it incorporates the QSEN competencies into their pre-licensure education (American Association of Colleges of Nursing, 2011). The Robert Wood Johnson Foundation has also sponsored an annual QSEN National Forum where nurse educators have been able to come together to share patient safety teaching strategies. Additionally, the QSEN website (http://www.qsen.org/) offers resources to assist nurse educators in planning course content. Resources include annotated bibliographies, learning modules, and teaching strategies.
Although the integration of these competencies across the curriculum can seem overwhelming, some early guidance can already be offered. Barton and colleagues (Barton, Armstrong, Preheim, Gelmon, & Andrus, 2009) conducted a Delphi study, using a developmental approach involving beginning, intermediate, and advanced stages of the curriculum, to identify where in the curriculum the various 162 QSEN competencies should be introduced and where they should be emphasized. Respondents recommended that patient safety competency be introduced early in the curriculum and emphasized during the intermediate and advanced phases of the curriculum. Many schools are indeed introducing the concept of patient safety in their Fundamentals of Nursing courses. This content may include The Joint Commission National Patient Safety Goals (Joint Commission, 2011) which enable students to learn about the categories of errors and hazards in care, the 5 Million Lives Campaign (Institute for Healthcare Improvement, 2011), and the Patient Identification with a Wrist Band Toolkit (Maryland Hospital Association, 2009). Intermediate and advanced content activities may include discussing research regarding the effects of interruptions on medication errors in a pharmacology course, practicing SBAR communication during handoff in a medical-surgical clinical rotation, and attending a root cause analysis during a capstone clinical experience. The National Council of State Boards of Nursing (2010), in their Transition to Practice model, has recommended that the QSEN competencies be incorporated into nurse residency programs for new-to-practice nurses. Although it is important to teach about cultures of safety in pre-licensure programs, the content should also be a component of ongoing, professional development programs across all healthcare agencies.
For educators to teach about the culture of safety, they must be knowledgeable and current regarding the components of a safe culture. Activities that may facilitate their being up-to-date include (a) becoming a member of a clinical agency quality improvement, patient safety, pharmacy, and/or other safety-related committee, (b) holding quarterly or twice yearly meetings among clinical agency chief nursing executives, clinical leaders, deans/ directors of schools of nursing, and key faculty, and (c) gaining familiarity with resources to use when teaching, including the QSEN website. It is important to include a variety of strategies in teaching about a culture of safety. These strategies can be taught in classrooms, simulation laboratories, and/or during clinical activities. Tables 3, 4, and 5 list multiple examples of teaching strategies for each of these areas.
Table 3. Teaching the Culture of Safety: Classroom Activities/Assignments
- Demonstrate prescribing, dispensing, and medication error vulnerabilities, and ways to avoid these vulnerabilities, during pharmacology classes
- Evaluate the research on work hours and fatigue and discuss how these affect quality of care and risk of errors
- Discuss sentinel event and Serious Reportable Event (SRE) ‘never event’ statistics
- Discuss The Joint Commission videos such as Speak Up: Prevent Errors in Your Care which may be accessed on you tube www.youtube.com/watch?v=EccuE-_2_2
- Use unfolding case studies incorporating multiple QSEN competencies within cases appropriate for the course content. See www.qsen.org website for examples
- Invite patients to attend class to tell their stories and what they want from healthcare providers
- Have participants work in teams when discussing clinical scenarios using problem-based learning
- Have students complete a root cause analysis using case scenarios and develop evidence-based change plans based on identified root causes
- Develop pocket guides, i.e., brief self-contained learning modules on the components of safety, for clinicians and students to use
Table 4. Teaching the Culture of Safety: Simulation Activities/Assignments
- Use a patient model to simulate safety breaches.
- Develop scenarios of various equipment failures and have participants detect and correct equipment problems
- Set up a clinical room with opportunities to identify and correct multiple hazards and errors
- Demonstrate how a near-miss or error is documented
- Have students practice SBAR for effective handoffs and communication between and among clinicians
- Use high fidelity clinical simulations to assess ability to deliver safe care in the clinical setting
- Ask students to read and interpret medication labels, some of which are set up correctly and some with errors. Have them rewrite labels for clearer understanding
- Use a complex set of discharge medication orders and ask participants to set up a schedule for medication administration and demonstrate the set-up using small candies
Table 5. Teaching the Culture of Safety: Clinical Activities for Students
- Observe and evaluate teamwork, communication, and collaboration during interprofessional rounds discussing patients
- Design a checklist for a common procedure e.g. insertion of a Foley catheter
- Serve as ‘secret shoppers’ and observe staff and other students’ technique, for example completing hand hygiene or handling interruptions. Track findings and report the data.
- Discuss near misses and adverse events with staff nurses
- Attend a Root Cause Analysis and/or a Failure Mode Effects Analysis meeting.
- Working within a group, develop a unit-based Quality Improvement project and engage an interprofessional team to implement the project. Share the results with students, faculty, and agency members
- Attend patient safety rounds
- Working within a group, develop a safety rounds checklist and make unit rounds to complete the checklist. Share results with staff and initiate a discussion of the findings
- Ask participants to review each other’s healthcare record documentation to assess for any errors in documentation
- Complete an environmental safety scan of a clinical area and evaluate space and lighting adequacy, as well as accessibility for patients, families, and staff. Assess traffic, noise, and accessibility of supplies and equipment including space for medication preparation.
- Work in teams including a nursing, medical, and pharmacy student to examine a complex patient health record and complete a medication reconciliation analysis from admission through discharge
- Design approaches to reduce interruptions, such as wearing vests during medication administration, and/or no interruption zones, such as the medication preparation area
- Have clinical Instructors incorporate reflective exercises on patient safety into clinical post conferences
- Ask faculty to develop and implement an error/near miss reporting system to trend student errors/near misses
In summary, making progress on moving the healthcare system to a culture of safety begins with students learning how to learn about safety. Safe, effective delivery of patient care requires that nursing students understand the complexity of healthcare systems, the limits of human factors, safety design principles, characteristics of high reliability organizations, and patient safety resources. These components are critical to the preparation of safe clinicians and essential for 21st Century healthcare delivery.
Jane Barnsteiner, PhD, RN, FAAN
Dr. Barnsteiner is Professor of Pediatric Nursing at the University of Pennsylvania, School of Nursing (Philadelphia). For the past 26 years she has served in joint appointments with the School of Nursing, and most recently, the Hospital of the University of Philadelphia (HUP), where, for a time she was the Director of Nursing Translational Research. Prior to her role at HUP she was Director of Nursing Practice and Research at The Children’s Hospital of Philadelphia. Dr. Barnsteiner served as a member of the expert group that developed the Quality and Safety Education in Nursing (QSEN) pre-licensure and graduate competencies. She is a member of both The Joint Commission Patient Safety Advisory Committee and the National Council of State Boards of Nursing Transition to Practice Study. Her scholarship focuses on evidence-based practice, translational research, and patient safety. Dr. Barnsteiner has been honored for her work by the Eastern Nursing Research Society (Distinguished Researcher Award) and by Sigma Theta Tau International (Dorothy Garrigus Adams Award for Excellence in Fostering Professional Standards). In 2009 she received the Lindback Award for Distinguished Teaching from the University of Pennsylvania. She received her BSN and MSN degrees in Maternal and Child Health from the University of Pennsylvania School of Nursing, and her PhD in Clinical Nursing Research from the University of Michigan.
Acronym finder. (2009). Retrieved on June 29, 2011 from www.acronymfinder.com/Safe%2c-Timely%2c-Effective%2c-Efficient%2c-Equitable%2c-Patient_Centered-(Care%3b-Baylor-Health-Care-System)-(STEEEP).html.
American Association of Colleges of Nursing. (2011). Quality and safety education for nurses (QSEN) education consortium. Retrieved from www.aacn.nche.edu/qsenec/index.htm
American Association of Critical Care Nurses. (2005). AACN standards for establishing and sustaining healthy work environments: A journey to excellence. American Journal of Critical Care, 14, 187-197.
Antonovsky, J.A., Smith, A.B., & Silver, M.P. (2000). Medication error reporting: A survey of nursing staff. Journal of Nursing Care Quality, 15(1), 42-48.
Association of periOperative Registered Nurses (AORN). (2006). AORN position statement: Creating a patient safety culture. Retrieved on October 20, 2009 from www.aorn.org/PracticeResources/AORNPositionStatements/Position_CreatingaPatientSafetyCulture
Bagin, J. P., Lee, C., Gosbee, J., DeRosier, J., Stalhandske, E., Eldridge, N.,…Burkhardt, M. (2001). Developing and deploying a patient safety program in a large health care delivery system: You can’t fix what you don’t know about. Joint Commission Journal of Quality Improvement, 27(10), 522-532.
Baker, D. P., Day, R., & Sales, E. (2006). Teamwork as an essential component of high-reliability organizations. Health Service Research, 41(4), 1576-1598.
Barenfinger, J., Sauter, R. L., Lang, D. L, Collins, S.M., Hacek, D.M., & Peterson, L.R. (2004). Improving patient safety by repeating (read-back) telephone reports of critical information. American Journal of Clinical Pathology, 121, 801-803.
Barnsteiner, J. (2012). Workplace abuse in nursing: Policy strategies. In D. Mason, J. Leavitt, M. Chafee (Eds). Politics and policy in nursing and healthcare (6th ed.) pp. 428-434.St Louis, MO: Elsevier Saunders.
Barton, A., Armstrong, G., Preheim, G., Gelmon S., & Andrus L. (2009) A national Delphi to determine developmental progression of quality and safety competencies in nursing education. Nursing Outlook.,57, 331-332.
Berwick, D. M., Calkins, D. R., McCannon, C. J., & Hackbarth, A.D. (2006). The 100,000 lives campaign: Setting a goal and a deadline for improving health care quality. In Institute for healthcare Improvement [Online]. Retrieved June 26, 2011, from www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/100000LivesCampaignSettingaGoalandaDeadline.html.
Brixey, J. (2010). Interruptions in workflow for RNs in a level one trauma center. Patient Safety and Quality Healthcare, March/April, 25-30.
Carrol, J. S., & Rudolph, J. W. (2006). Design of high reliability organizations in health care. Quality and Safety in Health Care, 15(Suppl. 1), i4-i9.
Clarke, S., & Donaldson, N. (2008). Nurse staffing and patient care quality and safety. In R. G Hughes (ed.), Patient safety and quality: An evidence-based handbook for nurses, (pp. 2-111–2-136). Rockville, MD: Agency for Healthcare Research and Quality (AHRQ), Publication No. 08-0043.
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch J., Johnson, J., Mitchell, P.,…Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122-131.
Cronenwett, L., Sherwood, G., Pohl, J., Barnsteiner, J., Moore, S., Sullivan, D.T.,…Warren, J. (2009). Quality and safety education for advanced practice nurses. Nursing Outlook. 57, 338–348.
Dayton, E., & Henriksen, K. (2007). Communication failure: Basic components, contributing factors, and the call for structure. Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources, 33(1), 34-47.
Denham, C. R. (2007). Trust: The 5 rights of the second victim. Journal of Patient Safety, 3, 107-119.
Elnitsky, C., Nichols, B., & Palmer K. (1997). Are hospital incidents being reported? JONA, 27, 40-46.
Evans, S. M., Berry, J. G., Smith, B. J., Esterman, A., Selim, P., O'Shaughnessy, J., & DeWit, M. (2006). Attitudes and barriers to incident reporting: A collaborative hospital study. Quality and Safety in Health Care, 15, 39-43.
Finkelman, A., & Kenner, C. (2009). Teaching IOM: Implications of the institute of medicine reports for nursing (2ndEd.). Silver Springs, MD: Nursebooks.org.
Friesen, M. A., White, S. V., & Byers, J. (2008). Handoffs: Implications for nurses. In R.G. Hughes (ed.), Patient safety and quality: An evidence-based handbook for nurses (pp. 2-285-2-333). Rockville, MD: Agency for Healthcare Research and Quality (AHRQ). Publication No. 08-0043. 34.
Haig, K. M., Sutton, S., & Whittington, J. (2006). National patient safety goals. SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources, 32(3), 167-175.
Hanna, D., Griswold, P., Leape, L. L, & Bates, D.W. (2005). Communicating critical test results: Safe practice recommendations. Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources, 31(2), 68-80.
Heath, J., Johanson, W., & Blake, N. (2004). Healthy work environments: A validation of the literature. JONA, 34(11), 524-530.
Hughes, R. G, & Blegen, M. A. (2008). Medication administration safety. In R. G. Hughes (Ed.) Patient safety and quality: An evidence-based handbook for nurses (pp. 2-397–2-458). Rockville, MD: Agency for Healthcare Research and Quality (AHRQ) Publication No. 08-0043.
Institute for Healthcare Improvement. (2011). Protecting 5 million lives from harm. Retrieved from www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/%205MillionLivesCampaign/Pages/default.aspx
Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
Joint Commission Center for Transforming Healthcare. (2010). Facts about handoff communication.Retrieved August 30, 2011 www.centerfortransforminghealthcare.org/projects/about_handoff_communication.asp
Joint Commission. (2008). Behaviors that undermine a culture of safety. Sentinel Event Alert. Issue 40. Retrieved August 30, 2011 from www.jointcommission.org/sentinel_event_alert_issue_40_behaviors_that_undermine_a_culture_of_safety/
Joint Commission. (2011). 2011 national patient safety goals now available: 2011 NPSG program links. Retrieved from www.jointcommission.org/standards_information/npsgs.aspx
Kohn, L. T, Corrigan, J. M., Donaldson, M. S. (Eds.) (2000). To err is human: building a safer health system. Washington, DC: National Academy Press.
Lamb, R. M., Studdert, D. M., Bohmer, R. M, Berwick, D.M., & Brennan, T.A. (2003). Hospital disclosure practices: Results of a national survey. Health Affairs, 22, 73- 83.
Lawton, R., & Parker, D. (2002). Barriers to incident reporting in a health care system. Quality and Safety in Health Care, 11, 15-18.
Maryland Hospital Association/Maryland Patient Safety Center. (2009). Get on the bandwagon for patient safety. Retrieved from ww.marylandpatientsafety.org/html/publications_tools/documents/Wristband_Toolkit_FINAL.pdf
Mitchell, P. (2008). Defining patient safety and quality care. In R.G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (pp. 1-1–1-6). Rockville, MD: Agency for Healthcare Research and Quality (AHRQ) Publication No. 08-0043.
National Council of State Boards of Nursing. (2010). Nursing pathways for patient safety. Mosby St. Louis, MS.
Nuckols, T. K., Bell, D. S., Liu, H., Paddock, S.M., Hilborne, L.H. (2007). Rates and types of events reported to established incident reporting systems in two US hospitals. Quality and Safety in Health Care, 16, 164-168.
Rassin, M., Kanti, T., & Silner, D. (2005). Chronology of medication errors by nurses: Accumulation of stresses and PTSD symptoms. Issues in Mental Health Nursing, 26(8), 873-886.
Reason, J. (2000). Human Error: Models and management. British Medical Journal, 320, 768-770.
Reiling, G. J., Knutzen, B. L., & Stoecklein, M. (2003). FMEA – the cure for medical errors. Quality Progress, 36, 67-71. Retrieved September 12, 2011 from www.medicalhealthcarefmea.com/guides/qp0803reiling.pdf
Riesenberg, L.A., Leitsch, J., & Cunningham, J.M. (2010). Nursing handoffs: A systematic review of the literature. American Journal of Nursing, 110(4), 24-34.
Rooney, J. J., & Vanden Heuvel, L. N. (2004). Root cause analysis for beginners. Quality Progress, 37. Retrieved June 29, 2011 from https://webspace.utexas.edu/mae548/www/research/digital%20forensics/qp0704rooney.pdf
Rossheim, J. (2009). To err is human – even for medical workers. Healthcare Monster. Retrieved June 29, 2011from http://healthcare.monster.ca/8099_en-CA_pf.asp.
Saint, S., Kaufman, S. R., Thompson, M., Rogers, M.A., Chenoweth, C.E. (2005). A reminder reduces urinary catheterizations in hospitalized patients. Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources, 31(8), 455-462.
Sexton, A., Chan, C., Elliott, M., Stuart, J., Jayasuriya, R., & Crookes, P. (2004). Nursing handovers: Do we really need them? Journal of Nursing Management, 12, 37-42. Retrieved September 12, 2011 from http://publicationslist.org/data/m.elliott/ref-10/Nursing%20handovers%20-%20do%20we%20really%20need%20them.pdf
Sherwood, G. (2011). Integrating quality and safety in nursing education and practice. Journal of Research in Nursing, 16, 226-239.
Shortell, S. M., Schmittdiel, J., Wang, M. C., Li, R., Gillies, R.R., Casalino, L.P., Bodenheimer, T., Rundall, T.G. (2005). An empirical assessment of high-performing medical groups: Results from a national study. Medical Care Research and Review, 62(4), 407-434. Retrieved September 12, 2011 from http://rds.epi-ucsf.org/ticr/syllabus/courses/66/2008/05/06/Lecture/readings/Assessment%20of%20high%20performing%20medical%20groups.pdf
Sorra, J., Famolaro, T., Dyer, N., Nelson, D., & Khanna, K. (2008). Hospital survey on patient safety culture 2008 comparative database report. (Prepared by Westat, Rockville, MD, under contract No. 233-02-0087, Task Order 18). Rockville, MD: Agency for Healthcare Research and Quality (AHRQ) Publication No. 08-0039. Retrieved September 12, 2011 from http://psnet.ahrq.gov/resource.aspx?resourceID=7104
Thurman, A. E. (2001). Institutional responses to medical mistakes: Ethical and legal perspectives. Kennedy Institute Ethics Journal, 11(2), 147-56.
Trbovich, P., Prakash, V., Stewart, J., Trip, K., & Savage, P., (2010). Interruptions during the delivery of high-risk medications. JONA, 40, 211-218.
Vicente, K. (2004). The human factor. New York, NY: Routledge.
Waldrop, W., Murray, D. J., Boulet, J. R., & Kraus J. F. (2009). Management of equipment anesthesia failure: A simulation-based resident skill assessment. Anesthesia and Analgesia, 109, 426-433.
Welsh, C., Flanagan, M., & Ebright, P. (2010). Barriers and facilitators to nursing handoffs: Recommendations for redesign. Nursing Outlook, 58, 148-154.
White, A. A., Waterman, A., McCotter, P., Boyle, D., & Gallagher, T. H. (2008). Supporting health care workers after medical error: Considerations for healthcare leaders. J Clin Outcomes Management, 15, 240-247.
Wolf, Z. R. (2005). Stress management in response to practice errors: Critical events in professional practice. PA-PSRS Patient Safety Advisory, 2(4), 1-4.
Wu, A. W. (2000). Medical error: The second victim. The doctor who makes mistakes needs help too. BMJ, 320(7237), 726-727.
Yates, G. R, Bernd, D. L., Sayles, S. M., Stockmeier, C.A., Burke, G., Merti, G.E. (2005). Building and sustaining a systemwide culture of safety. Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources, 31, 684-689.
© 2011 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2011
- The Clinical Nurse Leader (CNL)®: Point-of-Care Safety Clinician
Kathryn B. Reid, PhD, RN, APRN-BC, CNL; Pamela Dennison, MSN, RN, APRN-BC, (September 30, 2011)
- Patient Safety Culture: The Nursing Unit Leader’s Role
Christine Elizabeth Sammer, DrPH, RN, FACHE; Barbara R. James, DSN, RN, CNE (September 30, 2011)
- Nurses Create a Culture of Patient Safety: It Takes More Than Projects
Julianne Morath, MS, RN (September 30, 2011)
- Improving the Culture of Patient Safety Through the Magnet® Journey
Jane W. Swanson, PhD, RN, NEA-BC; Candice A. Tidwell, EdD, RN-BC (September 30, 2011)