The care delivery process is a complex endeavor that involves multiple individuals working under difficult conditions and performing complex and often detailed tasks. Human beings play an integral role in the delivery of health care, but human beings are fallible and can make mistakes. When processes and procedures are not designed to address human failings and prevent or mitigate the effects of error, such processes and procedures can set individuals up to fail. For example, when organizations use medications that have similar packaging but provide different therapies, and they store these medications near each other, they set up a scenario in which a provider is likely to inadvertently mix-up those medications, thus leading to an error and possibly significant patient harm.
To address safety risks in health care, organizations must take a systems-based approach, designing processes and procedures to prevent or mitigate the effects of human error and to ensure reliability and consistency. Such an approach may involve changing medication packaging to eliminate the chances of medication mix-ups, installing hand hygiene stations to ensure easy access to hand hygiene equipment, or designing a comprehensive assessment form which consistently examines and addresses a patient’s likelihood of falling. “Organizations that are succeeding in reducing error and increasing revenues are investing in a systems approach to safety and shifting their culture to embrace this approach,” says Angood. “When implemented well, system-based initiatives can decrease the likelihood of error, improve throughput, improve cost management, and enhance the organization’s recognition and reputation – thus furthering the demand for services,” says Angood.
Cultural change, however, does not come about when only one aspect of an organization pursues such change. It requires an organizationwide effort and leadership focus. It requires everyone to prioritize a systems approach to safety, including the financial leadership of the organization.