Chuck DiTrapano, RPh and Bailey Klingaman explore the meaning of a culture of safety in clinical organizations. By understanding the motivation of clinicians and application of technology to the practice, organizations can assess the value of safety to its company culture.
Having been a healthcare professional for a very long time, I often think about what motivated me to be in the line of work and how I’ve managed my professional career in that time. By professional career, I don’t mean my job or the decisions I made to advance in the field, but the impact I had on the profession and patients for whom I’ve provided my services. I’ve been fortunate to have worked in clinical environments where safety has not just been a stated priority, but a priority of practice ingrained in the culture.
The following questions can help you determine if safety is a priority in your organization.
1. What is a culture of safety?
2. What motivates a healthcare worker?
3. How does your organization utilize technology?
What is a culture of safety?
As I mentioned, I’ve been fortunate to work in healthcare settings where safety wasn’t just talked about but integrated in the company culture. A culture of safety occurs when the management of an organization puts such a priority on safe practices and responses that it becomes an integral part of the organization’s value system.
This can be established by training clinicians to identify potential risks before they occur, communication between the organization and clinicians regarding procedures and expectations, and the responses to medication errors and near misses that have been reported.
Training
A good question to ask an employer is, “How do you prepare me to do this job?” For clinicians, we may have years of education and experience to qualify us for the job, but every work environment presents its own challenges. When expectations do not match responsibilities, it is important to be able to rely on the training and resources available with ease.
Organizations with fewer errors are experienced in training their clinicians to recognize and respond to a variety of risks. This includes safe practices, as well as educational tools for timely referral. Retraining should be available when necessary, and without shame or punishment. Studies have shown that proactive and recurrent training make for a more reliable organization, as they reinforce the notion that the organization views error prevention as important.
It’s interesting to me that almost every job I’ve had requires me to take a course or quiz on phone etiquette, HIPAA, violence in the workplace, fire procedures, etc., but nothing on how to prepare a specific drug or standard practices for administration.
Acknowledging that while I will only use a handful of these in my practice, there are thousands of drugs in the Library of Medicine database. Having virtual, on-site training for clinicians, where they can move at their own pace and know that the procedure they are learning is up-to-date with FDA standards, is crucial to establishing a positive and standardized training experience for employees.
Expectations & Standardization
In order to have effective training protocols, it is first important to establish accurate expectations for the responsibilities, procedures, and standards for the practice. Having standardized processes is an essential element to creating a safe working environment.
A common observation I have made from investigating incident reports is the instance of an unexpected outcome. An unexpected outcome occurs when the patient experiences an adverse or negative reaction different from other patients. The first step to uncovering the cause of the unexpected outcome is to question if the clinical caregiver followed the organization’s documented procedure.
If the clinician did follow the procedure, an examination and rectification of the error’s cause is a simpler process because the procedure was clearly documented and followed. Updates can be made with precision that will better the preparation/administration of the drug for the entire organization and its patients.
If the clinician did not follow the procedure, then you are at a loss. You are unable to determine whether the error was caused by a flaw in the procedure used or a flaw in the healthcare professional. Since you are unsure of the error’s catalyst, making necessary adjustments and revisions becomes more of a guessing game than calculated decisions. This “did-not” situation also applies if there was no standardized procedure set forth in the beginning.
To reduce initial training time and establish confidence in both the caregiver and the patient, organizations should consider adhering to widely-recognized standard procedures, like NICA’s Minimum Standards for In-Office Infusion. Additionally, organizations should have well-defined procedures for the preparation and administration of every drug in its formulary readily available should a clinician require guidance.
By setting these standards and expectations for healthcare professionals, their focus can be on providing the best care possible, rather than recalling the correct procedure for their specific organization.
Response
At my last job, I spent 17 years reading about every medication error that was documented in our hospital. Our employer had instituted a “just culture”. In a just culture, both the administration and employees share the responsibility for upholding safe practices, recognizing that today’s healthcare is complex and has a level of risk. A just culture relies on the concept of trust: trust that the employee is following procedures and trust that the employer has their back.
In addition to training and communication on standards, employers can demonstrate their trustworthiness by establishing an error reporting system and process for responding to errors or near misses. The result of these processes and systems should be procedural improvement, relieving the employee of individual blame and accepting responsibility for the cause of the risk.
One proactive approach to establishing a system of trust is to create a culture of positive reinforcement. Either for individuals or teams, employees involved in improving safety practices can be rewarded for their efforts. Recognition can be informal (like a company-wide announcement thanking the employee for their dedication) or formal (promotions or raises based on safety performance).
A system based on rewards helps communicate what the organization does want, where a system of punishments only communicates what it does not want, without offering an alternative. However, it is important to acknowledge that while a rewarding system creates a healthier company culture compared to a system of punishment, the former is not infallible.
The organization must be sure to align the rewards with the actions being rewarded, and consistently review the standards that result in recognition. While improvements are welcome and encouraged, it is first and foremost the duty of the clinicians to provide care to the patient based on the procedure, not to search for faults. Over-rewarding attention to detail and critical thinking can lead to prolonged appointments or frequent procedural changes that impact the patient’s confidence in their care.
For an organization to truly create a just culture where safety is a priority of practice, it must create trust, communicate the goals of safety-related protocols, and frequently evaluate the results of any response or error reporting systems put in place. Prioritizing safety is not a singular decision or act, but a constant effort on behalf of both employees and the organization they represent.
What motivates a healthcare professional?
So far, all of this is reliant upon the motivation of the healthcare worker and the understanding that many clinicians enter the healthcare profession with the goal of helping people. However, like with the system of rewards, we must recognize that there are other things that might motivate someone to pursue a career in healthcare.
Financial Security
According to the Bureau of Labor Statistics, more than half of the top 20 highest paying occupations in the United States are within the field of healthcare. Further, positions within healthcare are expected to grow 13% between 2021 and 2031, meaning about 2 million more jobs in a decade.
It is fair to say that positions in healthcare are always in demand and pay well depending on the level of education, experience, and opportunity. With the median salary for pharmacists in 2023 at $128, 570 (and that’s only the eighth highest paying medical career), I think we can all admit that financial security played some role in our decision to pursue a healthcare career.
Job Satisfaction
It is my opinion that job satisfaction is a more significant contributor to the motivation of healthcare professionals. Knowing that at the end of the day your intervention improves someone’s quality of life not only keeps clinicians content with their duties, but is powerful enough to convince someone to enter the field.
The pride of helping another plays an important role in maintaining job satisfaction. If clinicians in your organization are no longer satisfied (this refers to the personal satisfaction of providing care), it is possible that they do not feel as if they are helping their patients to the best of their ability. It is probably time to reevaluate the priorities of the organization.
Professional & Personal Growth
A career in healthcare not only likely requires years of education, but demands the clinician be open to learning until the day they retire. Many healthcare professionals crave knowledge and seek challenges. They may be fascinated by their specialty, or simply desire a career that always presents them with something new.
Every patient is different, every clinician is different, and every situation is different. This presents unique challenges at every turn and prompts the clinician to constantly explore and question. Healthcare is a field for the curious, and those with inquisitive minds will find themselves growing and improving in both their professional and personal lives.
How does your organization utilize technology?
In 2005, I was involved in implementing a bedside barcode verification system for a 700-bed teaching hospital. It was the first time I had been involved in a project designed to significantly improve patient safety of that magnitude. It was also my first real introduction to a series of technological innovations that I have utilized to this day.
Technology & Patient Safety
Technology enhances patient safety in a variety of ways, including “automating tasks, introducing medical alerts…improving clinical decision-making, intercepting potential errors, reducing variation in practice,” and more.
Specific products like smart infusion pumps, electronic dashboards, and virtual medication guides lead to time and money saved, reduced medication errors, decreased miscommunications, and provider standardization.
Implementing New Technology
When I was implementing the barcode verification system at the hospital, our implementation team failed in communicating effectively with the rest of the staff. While those of us working on the project understood the benefits and goals of the new technology, the remainder of the staff was unaware of the specifics.
During and after the initial implementation, we faced significant obstacles that could have been avoided with accurate communication. For example, some of the staff believed the reason for the new barcode system was a billing issue, and that the barcode represented a revenue transaction.
What the implementation team should have done was explain the National Drug Code (NDC), and how the barcode number represented the manufacturer, the product, and the package size. We learned a vital lesson that when implementing any new system, communication and explanation can never be over-stressed.
Holding meetings, distributing handouts, and being available for questions regarding the system can make the transition simpler, and helps avoid preventable obstacles that can have a variety of impacts on the care of patients and job satisfaction of clinicians.
Making Technology Fit
Most of the patients in our hospital quickly benefitted from the implementation of the bedside barcode verification. However, challenges we hadn’t considered in our planning process began to emerge.
For instance, the NICU mostly utilized compounded drugs, not commercially-available drugs with assigned NDCs. How would we package the compounded drugs and what would we include in the barcode? Even if we solved that problem, how would we create barcode labels that would ensure medication accuracy?
Like with any new practice, technology is not fool-proof. Using technology requires planning, testing, preparing, and testing again. It can be a great addition to clinical procedures, saving time and money. But in order to get the most out of the technology put into practice, you must optimize your plan for different situations and uses.
Technology is only as helpful as we make it, and still requires the motive of the user to function to the best of its ability.
Ensuring that your practice prioritizes safety is a strong step to make, but you can take it a step further. Initiate training and safety protocols in your organization, understand what motivates your healthcare workers and make safety one of those motivators, and implement the use of technology for safety purposes. Do these, and your practice can develop a culture of safety that will resonate with your clinicians and patients far after their treatment is finished.
