Today's healthcare system faces many challenges -- an increasingly complex patient population, a nursing shortage, and lingering problems from the COVID-19 pandemic, such as supply issues. Each challenge adds a layer of complexity to an already complicated industry, where even the smallest error can result in patient harm. With these challenges, nurse accountability has become a growing topic.
Patient safety issues involving nurses have been shared in the media recently, some with legal implications that the profession hasn't previously seen. As nurses generally spend more one-on-one time with patients than other members of the care team, they're understandably concerned with how they may be held responsible for patient harm from what very well may be a system error.
Patient safety errors
While patient safety errors are not new, the growth of social media and increase in overall communication allows for more stories to be shared. We're likely hearing about instances of patient safety errors more now than ever before, though they've always existed.
In fact, it's been 20 years since the watershed To Err Is Human report was issued by the Institute of Medicine, which brought national concern about patient safety with its claim that as many as 98,000 people die in U.S. hospitals each year because of preventable medical errors.
Some sobering studies in recent years indicate that To Err Is Human actually underestimated the number of deaths caused by preventable errors. A 2019 analysis reported that an estimated 1.2 million are harmed each year by medical errors made in U.S. hospitals.
Research suggests that hospitals can take 17 years to adopt evidence-based best practices. How then can nurses and other caregivers contribute to advancing patient safety?
Eliminating patient harm
To combat patient safety errors, organizations focusing on healthcare quality improvement have developed and promoted frameworks for hospitals and health systems to adopt. One thing we've learned over the last two decades of research and practice is that improving patient safety is a complex, multifaceted problem, which won't be solved by piecemeal, ad hoc initiatives. Instead, moving the needle on patient safety requires a total systems approach and, first and foremost, the creation of a strong culture of safety within an organization.
With many quality improvement frameworks to choose from, one approach has sustained popularity and proven to improve patient safety -- the concept of high reliability. While high reliability has been prevalent in other industries for many years, it's truly picking up speed in the healthcare industry. The effort to create a culture of high reliability within health care is not only long overdue but encompasses the key elements to help organizations focus on what really matters when improving patient safety.
High reliability organizations use systems thinking to evaluate and design for safety, while acutely aware that safety is an imminent, changing threat. New safety risks continuously emerge, uncertainty is everywhere, and no two accidents are the same. Knowing this, high reliability organizations (HROs) aim to create an environment in which potential problems are anticipated, detected early, and virtually always responded to early enough to prevent patient harm (in the case of health care).
How nurses can promote high reliability through nurse accountability
The high reliability framework relies on five characteristics to reduce large system errors. Because HROs are only successful when the concept is embedded in the organization's culture, the journey to high reliability calls for every member of the care team to take part.
Below are a few examples of how nurses play a role in the high reliability journey, while demonstrating nurse accountability, as outlined by its five characteristics:
1) Preoccupation with failure
This entails being aware of and thinking about the potential for failure by understanding that new threats emerge regularly from situations that no one imagined could occur. It involves actively thinking about what could go wrong and staying alert to small signs of potential problems. Example: A nurse notices that one of their patients has not been reassessed for fall-risk, despite changes to their medication and recorded low blood pressure. The nurse speaks up to ensure the patient is reassessed as necessary.
2) Reluctance to simplify
This is the act of seeking underlying (often less obvious) explanations. Recognize the value of standardized workflows to reduce variation, while also understanding their complexity due to the number of teams, processes, and relationships involved in conducting daily operations. Example: An infection prevention effort is made to improve handwashing practices throughout the organization. During a meeting where the effort is introduced, a nurse notices that only caregivers are in attendance. The nurse raises concerns that other hospital employees were overlooked in the initiative.
3) Sensitivity to operations
This is to cultivate an understanding of the context of the current state of your work in relation to the unit or organizational state -- i.e., other units -- and how the current state might support or threaten safety. Example: An emergency room nurse notes that readmission rates are higher for patient populations with higher poverty levels and fewer resources like lack of transportation or caregiver support at home. The nurse recognizes the inefficiencies in the current standard discharge patient materials and follow-up instructions.
4) Deference to expertise
Understanding that the person with greatest knowledge of the situation might not be the person with the highest status and seniority is critical. Share concerns with others and advocate for a culture where others feel comfortable speaking up about potential safety problems. Example: A nurse notices a prohibited item in a patient's room, likely brought it in by a visitor. When the nurse returns during rounds, the patient's belongings have been moved. The nurse consults the housekeeping staff on duty to learn what visitors the patients had and when they left.
5) Commitment to resilience
This is the act of assuming the system is at risk for failure, and routinely practicing rapid assessments of and responses to challenging situations. Performing situation assessment and cross monitoring to identify potential safety threats quickly is necessary to show a real commitment to resilience. Example: Despite early success in a fall-reduction improvement project, progress begins to stall. Nurses begin to share near-miss examples during huddles and provide encouragement and meaningful recognition to fellow healthcare workers.
Addressing nurse accountability
Nurses understand the challenge of system issues or the difficulties that come with working in a culture that doesn't promote speaking up for patient safety -- regardless of the consequences. In these situations, nurses can call chain of command, and consider documenting their concerns.
Nurses have a right to practice within a culture that supports their commitment to patient safety. The nursing profession relies on the ability to simultaneously manage changing patient needs, continuously reprioritizing patient safety concerns.
Rather than viewing the characteristics of high reliability as "one more thing" to practice, nurses can benefit from embracing the principles as guidelines on when to speak up and when to ultimately say no if they feel they're being asked to compromise patient safety.
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