For companies around the world mistakes are often an inevitable part of doing business. Whether the mom and pop grocery store down the street or a world-wide conglomerate, mistakes will happen. These may result in a broken jar of pickles or a disastrous oil spill.
The health care field is likewise not immune from mistakes, but the Evans Army Community Hospital staff is striving for zero preventable harm to their patients and to become a High Reliability Organization.
"Ninety-nine percent mistake free is good for most things, but we cannot be comfortable with that," said Col. Dennis P. LeMaster, Evans hospital commander. "We have to look at it from the perspective of that person in the 1 percent who we didn't get right; we have to maximize every single patient encounter and be the best that we can be at all times."
Evans, along with other hospitals across the Army and the nation, is working to become an HRO, and to join the ranks of other organizations such as those in the airline and nuclear power industries. For these businesses a single mistake can have catastrophic consequences, but due to safeguards in place in the United States incidents are rare.
Unfortunately, that cannot be said for the health care industry. According to the Journal of Patient Safety as many as 400,000 preventable deaths occur every year in the United States in civilian hospitals.
"We know that bad things happen in hospitals, but it is the preventable harm that we are trying to get after here," said LeMaster. "It is acknowledging that human beings are not perfect and that they may make mistakes. So, we have to work to mitigate the human error."
Leadership is the key to creating a culture of safety and HROs follow five principles to mitigate error: preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience and deference to expertise.
The main trait of an HRO is a preoccupation with failure, being proactive in the prevention of errors by accounting for human limitations and building safeguards into processes. One of the safeguards that LeMaster encourages at Evans is that all staff members, regardless of position or rank, file patient safety reports whenever they see something wrong.
"Patient safety reports are important for us as an organization so that we can see what issues we have in the hospital and they help us track trends," said Cynthia Cisneros, Evans Patient Safety Coordinator.
But tracking the trends is only the first part of the process. Each clinic has a patient safety board where the trends, and safety messages, are posted to keep staff members aware of happenings throughout the hospital and the health care industry.
Reluctance to simplify is an important part of an HRO. Simple processes are good, but can lead to errors when shortcuts such as inadequate training, poor communication and failure to use checklists are used.
Another HRO trait is sensitivity to operations or situation awareness. Staff members should always be looking for the unusual and the unexpected in their workplace. Sometimes there are near misses that might cause harm and should be identified and viewed, not as proof that the system has effective safeguards, but as areas needing improvement.
"We have safeguards in place throughout the hospital to ensure the safety of our patients, but what happens when that safety net fails," said Cisneros. "By looking at near misses we can prevent errors from occurring in the future."
An HRO's commitment to resilience means that leaders and staff members need to recognize errors early to reduce the potential for harm, and they need to be trained to immediately respond when a system failure does occur. In short, staff accountability needs to be considered a positive rather than a negative event.
"When staff members file patient safety reports they do it to make their work place and our hospital a safer place for our patients and each other," said Cisneros. "These reports let us look at issues with our processes and how we can improve them."
The final trait, deference to expertise means that everyone in Evans hospital, regardless of position or rank has the responsibility to provide the safest environment for our patients.
The U.S. Army Medical Command's Deputy Commanding General (Operations) Maj. Gen. Jimmie O. Keenan said, "We [Army health care professionals] cannot improve patient safety and achieve zero preventable harm without integrating the principles of an HRO into our culture, a culture where our housekeepers, providers, nurses, medics, and our entire team are truly empowered and expected to advocate for our patients."
"We have a lot of patients who come through our doors at Evans hospital, and we have to maximize every single patient encounter because each one of them is important and deserves our very best," LeMaster told the Evans hospital staff at a recent town hall meeting. "Our most important patient is the one being seen at that exact moment in time, and that is who we are striving to be an HRO for.
"This journey to be an HRO is not like a hill that you seize and then you are done. It is work that goes on and on and on and never lets up, and I know that our highly-skilled staff at Evans is up to the task of catching that one percent."
Related Links:
Evans Army Community Hosptial Web Page
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