Creating a just culture
USA Health supports all its employees in reporting when errors occur, whether they be human-induced, technology-induced or system-induced.
The March conviction of a Tennessee nurse who reported making a medical mistake that resulted in the death of a patient has generated a significant amount of anxiety among the nursing profession, including here at USA Health.
More than a year ago, USA Health began the deliberative process of creating a just culture within the organization. The premise for this effort being that if we eliminate blame for errors, we have a better chance of getting to the root cause of a mistake. And once we find the cause, we can make the process changes necessary to prevent the error in the future.
In the vast majority of cases, processes, or lack of processes, create easier opportunities for healthcare providers to make mistakes. That is why it is important to examine the processes when there is an error. The airline industry set the standard for this approach, which drastically reduced fatal accidents through enhanced technology, improvement in air traffic control and pilot training.
Let’s make this as clear as possible – USA Health supports all its employees in reporting when errors occur, whether they be human-induced, technology-induced or system-induced. The only way to ensure the safest environment possible for our employees and our patients is to know about issues and find resolutions.
And you have demonstrated your trust in the system. Your reporting of issues has increased the safety to our patients and staff. One example is that through the reporting mechanisms, USA Health learned that staff was using make-shift dressings to prevent patients from pulling on their medical devices. The end result of the analysis was the health system purchasing medical grade mittens for use with patients - a much more effective, efficient and safe method for preventing patients from pulling on medical devices. But this would not have been the case if the make-shift dressings hadn’t been reported.
Safety reporting like this throughout the nation has led to drops in hospital-acquired infections, drug errors, patient falls and more.
The system is working. And we will continue to support you and your tremendous efforts to establish a just culture that improves the quality and safety of healthcare within USA Health.
Thank you for all you do to make USA Health a special place,
Owen Bailey, M.S.H.A., FACHE
Chief Executive Officer
Michael Chang, M.D., FACS
Chief Medical Officer
