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Striving for the impossible

The need to strive for the impossible in ward environments

Should nursing managers in highly reliable organisations accept that two patients in every 100 will fall, or should they urge staff to aim for zero harm?

Mrs Kinnon has just had a knee replacement. She has specific ambulation and fall precautions and needs a bed alarm at night. She is on a blood thinner and especially vulnerable to injury.

It is a Saturday night, staffing is tight and the handover report fails to state a bed alarm is needed. In the night, Mrs Kinnon becomes confused, she gets out of bed and later is found on the floor.

Doubts

Staff on the nursing unit are devastated at this outcome become they have worked so hard to prevent falls. They start doubting whether they will ever be able to

...

Should nursing managers in highly reliable organisations accept that two patients in every 100 will fall, or should they urge staff to aim for zero harm?


Nurses aiming for perfection highlights key factors in managing care
Picture: iStock

Mrs Kinnon has just had a knee replacement. She has specific ambulation and fall precautions and needs a bed alarm at night. She is on a blood thinner and especially vulnerable to injury.

It is a Saturday night, staffing is tight and the handover report fails to state a bed alarm is needed. In the night, Mrs Kinnon becomes confused, she gets out of bed and later is found on the floor. 

Doubts

Staff on the nursing unit are devastated at this outcome become they have worked so hard to prevent falls. They start doubting whether they will ever be able to eradicate falls on the unit altogether. During the daily morning safety huddle, someone asks: ‘Why do we keep striving for perfection when we can never achieve it?’

So why do we need to strive for perfection? If you were Mrs Kinnon or she was a member of your family, would you find the harm event tolerable?

Management

Highly reliable organisations (HROs) perform high-risk processes every day with few errors. They maintain this standard by predicting and preventing error before it occurs and by adapting safely to situations to mitigate harm. These organisations:

  • Recognise that, when small things go wrong, they are often early warning signs of something more serious.
  • Appreciate these warnings are red flags that provide insight into the health of the whole system.
  • Value near misses as indicators of early trouble and act on them to prevent future failure.
  • Are innovative, creative and value input from across the organisation.
  • Understand the importance of preparing for the unexpected.

High reliability is imperative in the complex, high-risk setting of healthcare delivery. Consumers do not expect or accept harm during treatment or hospitalisation; they expect to be protected, they expect zero harm, they expect high reliability.

Sustainability

High reliability in healthcare translates into positive outcomes and zero harm. The commitment of leadership and management to zero harm is crucial to sustaining and maintaining a culture of safety and high reliability. If healthcare leaders do not commit to zero harm, we are saying we expect and tolerate harm. So how much harm is tolerable? Two out of 100 patients can fall during their stay? Is it okay if five in 100 patients develop an infection when a urinary catheter is not removed after surgery? Are two patients every quarter allowed to have surgery in the wrong site?

Chief executive of the Cedars-Sinai Medical Center, in Los Angeles, Thomas Priselac says: ‘When you design for zero, you surface different ideas and approaches that, if you’re only designing for 90%, may not materialise. It’s about purposefully aiming for a higher level of performance.’

Anticipation and mitigation are the hallmarks of high reliability. High reliability does not require a new team or a new department. It requires a new mindset and nursing leadership is essential. Alignment of senior leadership, managers and bedside nursing staff is crucial.

In an HRO committed to zero harm, leading and sustaining a culture of safety is both a shared responsibility and the individual duty of everyone, in the nursing department or anywhere else in the organisation.


Reference

  • Oster C, Braaten J (2016) High Reliability Organisations: A Healthcare Handbook for Patient Safety and Quality. Sigma Theta Tau International, Indianapolis IN.

About the authors

Cynthia Oster is a clinical nurse specialist at Porter Adventist Hospital, Denver, Colorado. Jane Braaten is patient safety manager at Centura Health, also in Denver, Colorado.

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