Martha Goodfriend, RN, MEd
Cincinnati Children's Hospital Medical Center
Background: The study of human error in health care systems has been extensively described in the patient safety literature. Patient safety research has focused on human performance in complex systems, and the need to redesign reliable care delivery processes to improve patient outcomes. There is mounting evidence for healthcare organizations to adopt best practices to improve outcomes. Evidence-based improvements are well documented guiding organizations how to improve key care delivery processes and improved patient outcomes. However, few studies have been published describing how error prevention programs influence human performance in the context of daily care delivery, improve patient safety, and impact organizational culture. Method: This paper describes the design, implementation and evaluation of two components of an error prevention program in a pediatric academic medical center. The program established expected safety behaviors for clinicians to practice individually and within healthcare teams to reduce patient harm and advance the patient safety culture.
Results: The educational scorecard performance for this training program improved overtime. Staff positively evaluated the course as having provided new knowledge and skills, being a worthwhile organizational investment, and having value in terms of affecting patient outcome. Staff members were routinely observed in their clinical environments practicing the expected safety behaviors taught in the training program. Over a two-three year period, this organization demonstrated a measurable reduction in patient harm and a statistically significant improvement in the organization’s patient safety culture. And while these results are not fully attributable to the error prevention program, the program was a contributing factor to improved patient outcomes.
Discussion: This case review suggests that the staff can be taught error prevention techniques to improve both individual and team-based performance to reduce patient harm. These behaviors, when reinforced in the clinical environment, can influence team performance. Ongoing staff training and systems to support the reliable performance error prevention techniques are needed. These training programs when integrated with other improvement initiatives can positively impact a reduction of patient harm and positively influence the culture of patient safety.
