Overcoming Barriers to Patient Safety

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Executive SummaryThe IOM Report Keeping Patients Safe outlined five trouble spots leading to patient safety concerns on nursing units: unclear unit values, the fear of punishment for errors, the lack of systematic analysis of mistakes, the complexity of the work, and inadequate teamwork.When observing high reliability organizations (HROs), like air traffic control centers or nuclear power plants, a “culture of safety” transcends the culture and operations to manage unexpected events in a manner that minimizes fatal errors.These organizational characteristics and actions mirror the trouble spots outlined by the IOM: clarify values, encourage and reward reporting of mistakes, consistently analyze mistakes and near misses, look for the unexpected, simplify work, minimize interruptions, commit to resilience, encourage deference to expertise, and promote teamwork.Staff can begin the practice of error reporting by asking every team member to list one error or near miss during the past month during a staff meeting.Variations from critical pathways and assessment scales can be used as a tool to look for unexpected deviationsDevices that enable efficiency, like pagers and cell phones, may actually increase interruptions and lead to higher error rates.

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