Every day in every way

For healthcare employees, there are few things more painful than hearing a grieving mother describe how her young daughter, bravely fighting cancer, died while in hospital resulting from delays and lack of communication. Looking out on the audience that day on the Patient Safety Seminar, it was obvious that all of us felt her pain. After all, we got into medicine to assist people, heal the sick and maintain the weakest, but on this case we failed. Unfortunately, I even have heard versions of this mom’s story repeatedly over time. The details change, however the result is similar – lack of life or everlasting injury consequently of medical error.

We aren’t perfect, I tell myself as I hearken to these heartbreaking stories. We are human and sometimes, despite our greatest efforts, we fail. But inevitably, as I let their brave messages sink in, I take advantage of these heartbreaking stories to motivate me – to dig deeper and take a look at harder to turn into a more determined advocate for improving patient safety.

The theme for this 12 months’s American Nurses Association (ANA) National Nurses Week is: . Since the publication of a landmark report by the Institute of Medicine (IOM) in 1999, making a culture of safety has been a central focus of our occupation. The notion that medical errors that lead to patient harm and that they’re the results of system failure are largely preventable has created a platform for health care culture reform.

The IOM report provides clear recommendations for resolving medical errors. The government, skilled organizations, and health care organizations have worked to cut back preventable medical errors. There is a wealth of knowledge available about safety culture, including webinars, guides, frameworks, guidelines, etc. While now we have made progress, preventable harm happens in hospitals on daily basis.

So what’s safety culture? A culture of safety is an environment wherein patient care is secure and effective and patients are free from avoidable harm. The complexity of the systems wherein health care is delivered makes this difficult, but NO inconceivable.

So how can every nurse take a leadership role in creating and maintaining a high-reliability safety culture?

• Actively engage patients and their families as partners in care.
• Approach care delivery through interprofessional collaboration and teamwork.
• Promote a culture of innocent reporting of opposed events and near misses; analyze and learn from them.
• Implement evidence-based best practices; remove barriers to continued maintenance.
• Maximize using technology as intended.
• Improve communication around care transfers and transitions.
• Maintain a high level of situational awareness in your workplace to anticipate problems, e.g. incidents, crowding.
• Speak up should you witness or discover unsafe behavior or safety threats, and commit one another to secure practices.
• Set goals, measure results and promote data transparency.

This 12 months’s Nurses Week, let’s all make a commitment to ourselves, our teammates, and the people we take care of to turn into higher patient advocates. Let us learn from these heartbreaking stories of loss and take all essential steps to create and maintain an environment of a culture of safety – on daily basis and in every way.