High Reliability Relies on Systems Thinking and Staff Accountability

October 24, 2014 | Aging Services Risk, Quality, & Safety Guidance

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"Think about the front line clinician, the people who are working with the patient," Gary L. Sculli, MSN, ATP, director of clinical training programs and program manager, National Center for Patient Safety, reminded attendees of his 2014 National Aging Services Risk Management conference presentation, "A Culture of High Reliability: Balancing a Systems Focus and Accountability." High reliability stems from team training, awareness of human factors, regulatory protection, a high degree of standardization, rigorous checklist discipline, incentivized nonpunitive reporting, perpetual training, and performance review. Though the groundwork has been laid, Sculli pointed out that many of these have yet to gain significant traction within the healthcare environment. Nevertheless, even in a field where high reliability has been ingrained, such as aviation, zero errors is not realistic. Therefore, "what we have to create is fault tolerance," explained Sculli. A system is needed that will tolerate and catch errors while still promoting successful care and safety. Sculli pointed to the error management pyramid, which has a base of avoiding error, a middle layer of catching the error, and a point of mitigating the consequences of the error. Markers of high reliability include situational awareness, closed-loop communication, preoccupation with failure modes, standardized communication, a shared mental model, rule-based decision making, leadership engagement, and a systems-based response to error. Sculli pointed to a publication called The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives. "If the culture doesn't support it," he summarized, "It won't work." Three levels of situational awareness exist, Sculli said: perception, comprehension, and projection (i.e., acting on that comprehension).

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