Becker's Clinical Quality & Infection Control

12 INFECTION CONTROL & PATIENT SAFETY Pennsylvania hospital cited over 2 patient care incidents By Mackenzie Bean S tate health officials cited Lancaster (Pa.) Behavioral Health Hospital over two patient safety incidents that occurred in spring 2019, reported WPMT FOX43. A March 31 incident involved a patient who was supposed to have 24/7 supervision due to the risk of self-harm. An employee allowed the individual to close a curtain while using the bathroom, and the patient was later found not breathing. In a second incident, staff members gave a patient an incorrect medication dose. The medication error was flagged by the automated dispensing cabinet and when the medication was scanned for the patient, but staff members did not catch it. The error did not harm the patient. The 126-bed behavioral hospital submitted detailed plans of correction for both incidents to the Penn- sylvania Department of Health. Its license remains in good standing. n Why zero harm is a realistic goal for every hospital By Mackenzie Bean T he Joint Commission Center for Transforming Healthcare has a single, important mission: help health systems reach zero harm. e Joint Commission founded the Center in 2008 as a nonprofit affiliate and first started working with healthcare organizations to reduce healthcare-associated infection rates. About three years later, the Center expanded its focus to assess the systems and structures behind healthcare organizations. Today, the Center helps hospitals transform into high-reliability organizations that have systems in place to consistently avoid preventable harm. "Transforming to high reliability is a multiyear process, and it is probably the biggest change initiative any healthcare organization can undertake right now," said Anne Marie Benedicto, vice president of the Joint Commission Center for Transforming Healthcare. "A lot of people want to start the journey to high reliability, but don't know where to start." Ms. Benedicto spoke to Becker's about high-reliability organizations and shared how healthcare organizations can adopt high-reliability science to limit preventable harm. Editor's note: Responses have been lightly edited for style and clarity. Question: How realistic or attainable is the goal of zero harm? Anne Marie Benedicto: Mindsets regarding preventing harm have changed over the past few years, particularly around healthcare-ac- quired infections like central line infections or ventilator-associated pneumonia. We thought we could never eradicate them, and it was just a part of doing business. Now, we're actually seeing organizations get to zero harm for long periods of time for those specific infections. If you take that thinking and extrapolate it, it really is possible — with the right technology, mindset, skills and leadership — to create an organization that is so strong that zero harm is a byproduct of what they do. Q: What does a high-reliability organization look like? AMB: ere are three major characteristics of a highly reliable health- care organization. e first is a leadership commitment to zero harm. It isn't just about setting the goal of zero harm for the organization, but also making sure it is attainable by aligning resources around the goal. Second is a safety culture. e employees within an organiza- tion, including leadership, must recognize when harm could occur. ey need to be able to bring up unsafe conditions and opportunities for improvement. ey must also be able to solve and address the issues they bring up. e third characteristic is strong, robust process improvement skills. Performance improvement should be a common skill set in healthcare. ere needs to be massive training on quality improvement so people do it as part of their daily work. Q: What advice do you have for hospitals looking to incorporate high-reliability science into their quality improvement initiatives? AMB: It's important to have a leadership team that is aligned on what high reliability looks like. When we engage with organizations and talk to senior leaders, we quickly recognize they have many different definitions of what high reliability means. Making sure they are aligned in those concepts, along with their assessments of the or- ganization's strengths and opportunities of improvement, is a critical first step. Nothing else happens without that step. Q: Do you foresee more hospitals adopting high reliability in the future? Is this where quality improvement is moving? AMB: Yes, and mainly because the current state can't hold. We can't have people washing their hands 50 percent of the time. We can't have wrong-site surgeries happening at healthcare organizations, even aer years of investments to make organizations safer. We have to do something different to get a different outcome. And it's not due to bad employees or bad leaders. We all know that people enter healthcare committed and skilled. It's really about healthcare's systems and structures. Let's get the right ones in place so that the people who work within them can perform at the top of their game. Q: If you could fix one patient safety issue overnight, what would it be? AMB: Intimidating behaviors. e layers of intimidation in health- care organizations can lead to errors because people are so scared to speak up, ask questions or share ideas. is creates an unsafe envi- ronment because people who are not going to speak up will also hold their tongues when patients are involved. If you can't talk about the bad things, you can't talk about the good things either. e health- care organization misses out on identifying the unsafe conditions to prevent harm and also on the good ideas employees have to improve their organizations. n

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