A Culture of Safety: How to Achieve It

Psychiatrists with hospital-based or hospital-related practices are hearing a lot about the Joint Commission on Accreditation of Healthcare Organization’s (JCAHO) 2004 patient safety goals. Many organizations are calling for increased efforts to improve patient safety and reduce opportunities for medical errors.

A year ago, the APA Board of Trustees and Assembly approved a task force report on patient safety that contains recommendations for individual psychiatrists, psychiatrist leaders, training directors, and APA district branches and state associations. The report is available online at www.psych.org/psych_pract/pract_mgmt/apa_patientsafety_toc21003.pdf.

With this increased attention to patient safety, model practices and procedures are emerging, but the whole process of improvement begins with the establishment of a culture of safety.

Ken Kizer, M.D., M.P.H., president and CEO of the National Quality Forum, defines such a culture this way: “A culture of safety is an integrated pattern of individual and organizational behavior and its underlying philosophy and values, that continuously seeks to minimize hazards and patient harm that may result from the processes of care.”

It’s the “underlying philosophy” that is tricky. In many instances, it is influenced simultaneously by the genuine desire to give the best care to patients while avoiding lawsuits. Members of the APA task force agreed that “many physicians believe they should never make a mistake or at least never expose a mistake. Most physicians have trained and perform in an atmosphere that supports silence when an adverse event or ‘near miss’ occurs. Many physicians also recognize that errors in health care are more likely to result from failures in complex and interdependent medical, administrative, and communication processes rather than individual culpability. In light of this, susceptible environments that nearly or actually result in patient harm or death require systemwide redress, calling into question the basic notions of institutional culture regarding reporting and remediation. Culture change challenges this institutionally learned behavior.”

It is hard to change a culture, even when everyone involved knows patient care may improve by learning from adverse events or near misses. Replacing the old shame and blame way of dealing with adverse medical events with discussion and understanding of how adverse events occur and how they can be prevented in the future can bring about satisfaction in seeing real improvements in patient safety.

At APA’s 2004 annual meeting in New York, the APA Committee on Patient Safety will present a workshop titled “The Blame and Shame Game for Medical Errors: Do You Want to Play It?” at 9 a.m. on Thursday, May 6, in Room 1E01/2 on level l of the Javits Center. Psychiatrists Geetha Jayaram, M.D., Robert Michels, M.D., David McDowell, M.D., Ben Grasso, M.D., and others will portray and compare the traditional model and a nonpunitive systems model of reviewing both administrative and clinical treatment elements that lead to error reduction.

The APA committee encourages all psychiatrists to get involved in the patient safety committees and activities in hospitals and district branch/state associations. The committee also hopes all psychiatrists will join them for the workshop on May 6. ▪

Al Herzog, M.D., is chair of the APA Committee on Patient Safety; Claudia Hart is director of APA’s Department of Quality Improvement and Psychiatric Services.