Lessons from Other Industries’ Zero Harm Initiatives

Many patient safety initiatives are inspired by successful practices, particularly the adoption of technologies from other industries. The BMJ Quality and Safety Journal notes in “Technology as Applied to Patient Safety: An Overview”:

“Various industries have achieved advancements in safety by embracing technology. Manufacturing, for instance, has minimized reliance on human labor by implementing machine-based systems to produce top-notch products. In aviation, there’s been a clear recognition of the potential for human error, leading to a deliberate effort to mitigate error through strategic use of technology and automation.”

However, patient safety hasn’t seen the same level of improvement in harm reduction as other industries employing similar techniques. What sets patient safety apart?

One Major Distinction: The Human Element

It’s easy to think that what works in one high-risk industry can be applied to another, but the authors of the BMJ caution against this assumption:

Healthcare involves much more direct interaction than many other high-risk industries. It requires skilled interventions, adaptability, flexibility, and, most importantly, empathy and compassion. Technology can assist, but it can’t replace human beings.

Healthcare stands out because treating patients is more complex than dealing with even the most advanced machinery. Minimizing harm to patients adds another layer of complexity to decision-making. While procedures for handling issues with an aircraft, for instance, might be standardized, dealing with human bodies requires more subtlety and context. Ethical considerations, compassion, and empathy further complicate standardization efforts.

Silos Add another Layer of Complexity

Another reason why Zero-Harm efforts struggle in patient safety environments is the highly siloed nature of healthcare organizations. Eileen T. O’Grady, Ph.D., R.N., N.P., in her book “Patient Safety and Quality: An Evidence-Based Handbook for Nurses,” notes that this siloing often begins during training:

“The Institute of Medicine emphasizes that teams deliver most care today, yet training often focuses on individual roles, leaving practitioners unprepared for complex settings. Silos formed during training and care organization hinder safety improvements.”

The PSQH article mentioned earlier quotes Jeffrey Brady, MD, MPH, co-chair of the National Steering Committee and director of the Center for Quality Improvement and Patient Safety, who highlights the need to break down silos as a key goal of the National Action Plan. “We know that no single person or organization alone can ensure patient safety. Collaboration is essential,” said Brady.

Culture can also Act as a Barrier to Progress

A paper in the Journal of Patient Safety and Risk Management titled “What is the role of technology in improving patient safety? A French, German, and UK healthcare professional perspective” dives into various aspects, including the connection between technology and organizational culture:

Institutional culture may hinder the adoption and optimization of existing technologies. 

No technological innovation or improvement will succeed if healthcare services and workers do not embrace it. A cultural shift across all levels of healthcare infrastructure, from clinicians to international organizations, could be the most significant change to enhance the benefits of current or future technology.

A recent study published in the journal Leadership in Health Services highlighted significant disparities in how managers and staff perceive critical areas of patient safety (PS) and patient safety culture (PSC):

The poorest results were in areas related to managers’ expectations and actions to promote and support PS. Staff felt that the organization wasn’t learning from reported mistakes or providing sufficient feedback. This approach doesn’t help learning from experience, and the absence of feedback may lead staff to believe that managers aren’t interested in incident reporting. Secondly, the lack of feedback and communication about incident reports may indicate that staff are unsure about the process after a report is submitted. As the literature suggests, managers’ disregard for how they are perceived by staff may discourage reporting and harm the organization’s PSC.

Viewing Technology as a “Silver Bullet”

Technology is often seen as the answer to many healthcare challenges. A study assessing technology’s effectiveness in healthcare concluded:

“Health information technology improves patient safety by reducing medication errors, adverse drug reactions, and improving compliance with practice guidelines. There’s no doubt that health information technology is decisive for enhancing healthcare quality and safety.”

However, the promise of technology is often overshadowed by the frustrations end-users encounter when trying to adapt their processes to a new system. One vendor, in an article for The Hospitalist, pointed out: “Workarounds are common in healthcare because many tools and technologies hinder rather than improve a clinician’s efficiency.” Cheng-Kai Kao, MD, medical director of informatics at the University of Chicago Medicine, added, “We’re talking about usability. We need to optimize the IT system so it integrates smoothly into people’s daily workflow, avoiding disruptions that lead to workarounds.”

While technology can bring significant benefits to patient safety efforts, it can also make practitioners less efficient if not implemented properly. A successful healthcare IT strategy will need to address these conflicting challenges.

A Structured Framework Comprising Six Coordinated Imperatives

In a recent white paper titled “Improving Patient Safety: 6 Ways to Move Beyond the Status Quo,” we introduce an integrated approach aimed at overcoming silos and addressing roadblocks in patient safety culture, all while keeping the focus on the patient.

To tackle challenges related to patient safety and quality, patient safety teams and healthcare organization leaders should:

1. Promote an inclusive, non-punitive culture where everyone feels accountable and encouraged to report events transparently. Leadership should organize this cultural shift, cascading change throughout the organization from top executives to all employees.
2. Break down data and information silos that hinder operations, morale, and a productive culture.
3. Implement frameworks and standards that combine qualitative and quantitative data, making technology accessible to all employees.
4. Deploy risk management technology that integrates seamlessly with existing systems, adapting to specific locations and markets. Solutions should enable anonymous incident reporting without fear of retaliation.
5. Enhance communication channels to improve alignment and decision-making across the organization, empowering every member to play an active role.
6. Integrate technology solutions to maximize efficiency and user experience, ensuring that the whole system is greater than the sum of its parts.

Compared to current fragmented approaches, the coordinated six-point approach recognizes that each solution alone cannot bring about sustainable change across the entire organization. For instance, if data silos persist, technology cannot effectively promote a safety culture, hindering open communication needed to address safety events and transparency. By automating tasks like adverse event reporting and data sharing, clinicians can focus more on patient care, reducing burnout and empowering them to deliver better care. This ultimately leads to improved financial performance, staff retention, and a lower risk of future safety incidents.

An Essential Aspect to Consider is Configurability

As highlighted in the Journal of Patient Safety and Risk Management article, technology solutions should be flexible enough to be customized to fit the structure and needs of an institution. Leading technology solutions can be tailored to specific use cases rather than requiring users to adjust their processes to fit the technology. As Dr. Kao emphasizes in The Potential Dangers of Using Technology in Healthcare, simplifying the right tasks encourages people to do the right thing, aligning with our goal.

In a healthcare risk management system like Origami Risk, platform configurability refers to the ease of accommodating client-specific requests without costly and time-consuming code changes. This flexibility empowers system administrators—whether designated team members or Origami Risk service personnel—to implement system adjustments and introduce new features as needed swiftly.

Examples of Origami Risk’s Platform Configurability include:

Fields and Codes :  Screens, field names, and codes can all be customized to support the preferences of departments, teams, or other stakeholders within and outside the organization.

User Settings and Permissions: Detailed security roles can be established and enforced to ensure that users only access the data and system components for which they are authorized.

Business Rules and Workflows: Organizations can define specific event-handling processes and automate tasks to reduce reliance on manual procedures, which can be time-consuming and prone to errors.

Data Tools & Integrations :The capability to aggregate, clean, reformat, and exchange data with various sources helps to break down data silos commonly found in healthcare organizations.