Safety Culture: Identifying a Healthcare Organization’s Approach to Safety Event Review and Response Through the Analysis of Event Recommendations

Authors

  • Ella S. Franklin, MSN Medstar Health National Center for Human Factors in Healthcare
  • Jessica L. Howe, MA MedStar Health National Center for Human Factors in Healthcare
  • Ram A. Dixit, MS MedStar Health National Center for Human Factors in Healthcare
  • Tracy C. Kim, BS MedStar Health National Center for Human Factors in Healthcare
  • Allan Fong, MS MedStar Health National Center for Human Factors in Healthcare
  • Katharine T. Adams, BA MedStar Health National Center for Human Factors in Healthcare
  • Raj M. Ratwani, PhD MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine
  • Rebecca Jones, MBA, RN Patient Safety Authority
  • Seth Krevat, MD MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine

DOI:

https://doi.org/10.33940/culture/2021.6.7

Keywords:

safety culture, event review, person-based, system-based, patient safety

Abstract

Safety Culture - visual abstract

A nonpunitive approach to safety event reporting and analysis is an important dimension of healthcare organization safety culture. A system-based safety event review process, one focused on understanding and improving the conditions in which individuals do their work, generally leads to more effective and sustainable safety solutions. On the contrary, the more typical person-based approach, that blames individuals for errors, often results in unsustainable and ineffective safety solutions, but these solutions can be faster and less resource intensive to implement. We sought to determine the frequency of system-based and person-based approaches to adverse event reviews through analysis of the recommendation text provided by a healthcare organization in response to an event report. Human factors and clinical safety science experts developed a taxonomy to describe the content of the recommendation text, reviewed 8,546 event report recommendations, and assigned one or more taxonomy category labels to each recommendation. The taxonomy categories aligned with a system-based approach, aligned with a person-based approach, did not provide an indicator of the approach, or indicated the review/analysis was pending. A total of 9,848 category labels were assigned to the 8,546 event report recommendations. The most frequently used category labels did not provide an indicator of the approach to event review (4,145 of 9,848 category labels, 42.1%), followed by a person-based approach (2,327, 23.6%), review/analysis pending (1,862 ,18.9%), and a system-based approach (1,514, 15.4%). Analyzing the data at the level of each recommendation, 23.2% (1,979 of 8,546) had at least one person-based and no system-based category, 13.3% (1,133) had at least one system-based and no person-based category, and 3% (254) had at least one person-based and one system-based category. There was variability in the event review approach based on the general event type assigned to the safety event (e.g., medication, transfusion, etc.) as well as harm severity. Results suggest improvements in applying system-based approaches are needed, especially for certain general event type categories. Recommendations for improving safety event reviews are provided.

Author Biographies

Ella S. Franklin, MSN, Medstar Health National Center for Human Factors in Healthcare

Ella Franklin is the nursing director at the MedStar Health National Center for Human Factors in Healthcare.

Jessica L. Howe, MA, MedStar Health National Center for Human Factors in Healthcare

Jessica Howe is a research scientist and system safety specialist at the MedStar Health National Center for Human Factors in Healthcare.

Ram A. Dixit, MS, MedStar Health National Center for Human Factors in Healthcare

Ram Dixit is a human factors specialist at the MedStar Health National Center for Human Factors in Healthcare.

Tracy C. Kim, BS, MedStar Health National Center for Human Factors in Healthcare

Tracy Kim is a research and program coordinator at the MedStar Health National Center for Human Factors in Healthcare.

Allan Fong, MS, MedStar Health National Center for Human Factors in Healthcare

Allan Fong is a senior research scientist with the MedStar Health National Center for Human Factors in Healthcare.

Katharine T. Adams, BA, MedStar Health National Center for Human Factors in Healthcare

Katharine Adams is a data scientist with the MedStar Health National Center for Human Factors in Healthcare.

Raj M. Ratwani, PhD, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine

Raj Ratwani is the director of the MedStar Health National Center for Human Factors in Healthcare, vice president of scientific affairs at the MedStar Health Research Institute, and an associate professor at Georgetown University School of Medicine.

Rebecca Jones, MBA, RN, Patient Safety Authority

Rebecca Jones (rebejones@pa.gov) is director of Data Science and Research at the Patient Safety Authority and founder and director of the PSA’s Center of Excellence for Improving Diagnosis.

Seth Krevat, MD, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine

Seth Krevat is the senior medical director and assistant vice president for Safety at MedStar Health and a faculty associate at the MedStar Health National Center for Human Factors in Healthcare and an assistant professor at Georgetown University School of Medicine.

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2 patients charts on blue background.

Published

2021-06-17

How to Cite

Franklin, E. S., Howe, J. L., Dixit, R. A., Kim, T. C., Fong, A., Adams, K. T., Ratwani, R. M., Jones, R., & Krevat, S. (2021). Safety Culture: Identifying a Healthcare Organization’s Approach to Safety Event Review and Response Through the Analysis of Event Recommendations. Patient Safety, 3(2), 92–103. https://doi.org/10.33940/culture/2021.6.7

Issue

Section

Original Research and Articles
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