Pitcher Partners recently collaborated with international expert on patient safety, Dr Raj Behal, to better understand safety culture and its influence on adverse events.
Key insights form our work together include:
To develop a safety culture, an organisation must respect its hazards and risks. This includes removing normalisation of hazards such as the confusion between “adverse event” and “known complications of surgery”.
Without strong safeguards, safety systems are vulnerable to adverse cultures. Leaders need to make their safety system ‘culture-proof’. This should be focussed on supporting learning and taking action.
A culture that does not value learning cannot be a safety culture. Organisations must value learning from mistakes or near misses rather than just looking at human errors or policy violations. Sharing the learnings, and actions to be taken, will also strengthen the safety culture.
You must have a plan that resonates with people’s values and intrinsic motives. Make sure you understanding “why” staff turn up to work every day, as poorly designed metrics and incentives can “crowd out” intrinsic motives.
Global progress in patient safety is too slow, as a result of:
First-order problem solving – undertaking superficial analysis, and using basic interventions (eg policy change, staff education)
Blind spots – pursuit of a single “root cause” or blaming culture
Ignoring hazards, near misses and unsafe conditions, and waiting for harm before intervening
Single-loop learning – not learning from aggregated cases, not questioning assumptions
Not suing safety sciences, such as systems thinking, human factors, design, computation, and behavioural/cognitive psychology
Pitcher Partners will continue to work with Dr Behal to share his Safety Steps and improve the safety culture in healthcare organisations.
If you would like to know more about how Safety Steps can help your organisation’s safety culture, please contact Michelle McDade, Client Director at Pitcher Partners