Feature
The human condition
Holistic approaches to a quality and safety program
Q
uality and safety go hand- in-hand; by improving one, the other improves as well. Creating a quality and
safety program is vital to the function of any IR practice or division, but to have a truly effective program, human emotion and good data must combine into productive and safe outcomes, according to panelists at the SIR 2023 session “Building a Quality and Safety Program.”
Evaluating mistakes The goal of a quality and safety program is to create a learning environment where patient safety is consistently optimized through a commitment to preventing, understanding and reliably responding to medical errors, said Mikhail Higgins, MD, MPH.
“When we talk about errors, complications and adverse events, we have to understand that not all poor outcomes are the result of an error,” he said. “There are so many contributors to something going wrong, which may be both individual or more commonly systemic.”
When something goes wrong, people want an answer, Dr. Higgins said, and in many situations the investigation doesn’t get past the individual level. Thus, the backlash focuses not on the flawed situation or processes that likely gave rise to the incident in question, but on the person deemed responsible.
“A huge barrier to an effective safety and quality program is fear,” Dr. Higgins said, which perpetuates silence and future errors. “Medical culture has not been traditionally supportive
of disclosing errors, and there is an associated fear of liability, retribution and professional discord.”
To succeed in your commitment to quality and safety, Dr. Higgins said, facilities and physicians must transition from a culture of shame to a learning culture that values the local rationality principle. Dr. Higgins said that this principle asks us to presume that no one comes to work wanting to do a bad job, but also calls us to seek to understand not where people went wrong but why what they did made sense to them. A robust safety culture built on shared learning from errors is associated with fewer events and fewer barriers to adverse event reporting—and when errors occur, it constructively shifts the question from who to why.
Understanding the factors “Everyone makes mistakes,” said Noor Ahmad, MD. It’s the first thing to understand when engaging in a safety culture. No one comes to work intending to do a bad job, and it’s more important to understand the factors that led to error.
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