Evaluating the Use of High-Reliability Principles to Increase Error Event Reporting

Duffey, Pam; Oliver, JoAnn S.; Newcomb, Patricia

doi:10.1097/nna.0000000000000758

Cited by 4 publications

(5 citation statements)

References 12 publications

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“…1). 8,19,30–36 Data extraction for these studies is available in Appendix B, http://links.lww.com/JPS/A352 and quality assessment in Appendix C, http://links.lww.com/JPS/A353.…”

Section: Resultsmentioning

confidence: 99%

“…We identified articles from 9 health care organizations that reported effects of HRO initiative implementation on patient safety, safety culture, and/or other process outcomes (Table 3). 8,19,[30][31][32][33][34][35][36] Of note, only 1 study explicitly described using one of the implementation frameworks described earlier (i.e., the IHI framework). 30 Of the 9 studies, 4 stood out as implementing the most comprehensive, multicomponent HRO initiatives.…”

Section: Effects Of Hro Implementationmentioning

confidence: 99%

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Implementing High-Reliability Organization Principles Into Practice: A Rapid Evidence Review

Veazie¹,

Peterson²,

Bourne³

et al. 2020

J Patient Saf

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Objective: To promote a safety culture and reduce harm, health care systems are adopting high-reliability organization (HRO) principles. This rapid review synthesizes HRO frameworks, metrics, and implementation effects to help inform health systems' efforts toward becoming HROs.Methods: Bibliographic databases were searched from 2010 to 2019.One reviewer used prespecified criteria to assess articles for inclusion, evaluate study quality, extract data, and grade strength of evidence with second reviewer checking.Results: Twenty-three articles were identified: 8 described frameworks, 9 examined metrics, and 9 evaluated implementation outcomes. Five common strategies for HRO implementation emerged (developing leadership, supporting a culture of safety, providing training and learning, building data systems, and implementing quality improvement interventions). The Joint Commission's and Institute for Healthcare Improvement's frameworks emerged as the most comprehensive and widely applicable. The Joint Commission's Oro 2.0 metric for evaluating HRO progress similarly stood out as it was developed through broad stakeholder input and was validated by external researchers. Multicomponent HRO interventions delivered for at least 2 years were associated with improved process and patient safety outcomes. Because each HRO intervention was only supported by a single poor or fair-quality study-none of which contained a concurrent control group-a causal relationship between any HRO initiative and outcomes could not be established.Conclusions: Health care system adoption of HRO principles is associated with improved safety outcomes, yet the level of evidence is low. Priorities for future HRO studies include use of concurrent control groups and examination of specific outcomes measurements.

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“…1). 8,19,30–36 Data extraction for these studies is available in Appendix B, http://links.lww.com/JPS/A352 and quality assessment in Appendix C, http://links.lww.com/JPS/A353.…”

Section: Resultsmentioning

confidence: 99%

Section: Effects Of Hro Implementationmentioning

confidence: 99%

Implementing High-Reliability Organization Principles Into Practice: A Rapid Evidence Review

Veazie¹,

Peterson²,

Bourne³

et al. 2020

J Patient Saf

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“…The importance of patient safety culture is well established, and study results indicate a link between use of safety culture survey findings and improved patient safety outcomes. [12][13][14] Patient safety culture is conceptually complex and can be viewed within the Patient Safety Culture Theoretical Framework, which is made up of these components: (a) degree of psychological safety, (b) degree of organizational culture, (c) quality of culture of safety, (d ) degree of high reliability organization, (e) degree of deference to expertise, and (f ) extent of resilience. Degree of psychological safety refers to feeling secure that one will not be punished when a mistake is made.…”

mentioning

confidence: 99%

“…According to the recent Survey on Patient Safety Hospital database report, 11 patient safety culture reflects what is rewarded, supported, expected, and accepted in an organization regarding patient safety. The importance of patient safety culture is well established, and study results indicate a link between use of safety culture survey findings and improved patient safety outcomes 12–14 …”

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confidence: 99%

Factor Structure and Construct Validity of a Hospital Survey on Patient Safety Culture Using Exploratory Factor Analysis

et al. 2023

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Objective: Nurses' voluntary reporting of adverse events and errors is critical for improving patient safety. The operationalization and application of the concept, patient safety culture, warrant further study. The objectives are to explore the underlying factor structure, the correlational relationship, between items of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture and examine its construct validity.Methods: Exploratory factor analysis was conducted using secondary data from the instrument's database. Using pattern matching, factors obtained through exploratory factor analysis were compared with the 6-component Patient Safety Culture Theoretical Framework: degree of psychological safety, degree of organizational culture, quality of culture of safety, degree of high reliability organization, degree of deference to expertise, and extent of resilience.Results: 6 exploratory factors, explaining 51% of the total variance, were communication lead/speak out/resilience, organizational culture and culture of safety-environment, psychological safety-security/protection, psychological safety-support/trust, patient safety, communication, and reporting for patient safety. All factors had moderate to very strong associations (range, 0.354-0.924). Overall, construct validity was good, but few exploratory factors matched the theoretical components of degree of deference to expertise and extent of resilience.Conclusions: Factors essential to creating an environment of transparent, voluntary error reporting are proposed. Items are needed, specifically focusing on deference to expertise, the ability of the person with the most experience to speak up and lead, despite hierarchy or traditional roles, and resilience, which is coping and moving forward after adversity or mistakes. With future studies, a supplemental survey with these items may be proposed.

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“…Safety culture gives “safety priority over efficiency, improving care provider communication and collaboration, and creating a system that learns about and learns from errors and problems.”7 (p139) A learning orientation, systems thinking, and the expectation of transparency echo the Institute for Healthcare Improvement's National Steering Committee recommendations: “they create the fertile soil that allows broader safety initiatives to take root and be cultivated.”8 (p6) High Reliability Organizations model similar values: preoccupation with failure, deference to the expertise of those closest to the work, and absolute transparency 9. The Institute for Healthcare Improvement saw the wisdom of using Improvement Science and strategies native to High Reliability Organizations to reduce harm 10.…”

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confidence: 99%

Improving Reporting Culture Through Daily Safety Huddles

MacKay

Jordan

Powers

et al. 2023

Quality Management in Health Care

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Background and Objectives: A major obstacle to safer care is lack of error reporting, preventing the opportunity to learn from those events. On an acute care unit in a children's hospital in southeastern United States, error reporting and Survey for Patient Safety Culture (SOPS 1.0) scores fell short of agency benchmarks. The purpose of this quality improvement project was to implement a Safety Huddle Intervention to improve error reporting and SOPS 1.0 scores related to reporting. Methods: Marshall Ganz's Change through Public Narrative Framework guided creation of the project's intervention: A story of self, a story of us, a story of now. A scripted Safety Huddle was conducted on the project unit daily for 6 weeks, and nurses on the project unit and a comparison unit completed the SOPS 1.0 before and after the intervention. Monthly error reporting was tracked on those same units. Results: Error reporting by nurses significantly increased during and after the intervention on the project unit (P = .012) but not on the comparison unit. SOPS 1.0 items purported to measure reporting culture showed no significant differences after the intervention or between project and comparison units. Only 1 composite score increased after the intervention: communication openness improved on the project unit but not on the comparison unit. Conclusion: Using a Safety Huddle Intervention to promote conversation about error events has potential to increase reporting of errors and foster a sense of communication openness. Both achievements have the capacity to improve patient safety.

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Evaluating the Use of High-Reliability Principles to Increase Error Event Reporting

Cited by 4 publications

References 12 publications

Implementing High-Reliability Organization Principles Into Practice: A Rapid Evidence Review

Implementing High-Reliability Organization Principles Into Practice: A Rapid Evidence Review

Factor Structure and Construct Validity of a Hospital Survey on Patient Safety Culture Using Exploratory Factor Analysis

Improving Reporting Culture Through Daily Safety Huddles

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