Saturday, March 31, 2012

AHRQ Report: Shame-and-Blame Culture Still Prevalent in Many Hospitals

It’s been five years since the Agency for Healthcare Research and Quality (AHRQ) dispensed its first report on patient-safety culture in hospitals. In that 2007 report, AHRQ said that hospitals should shed the shame-and-blame philosophy in dealing with errors and adopt a “culture of safety” that encourages employees to discuss mistakes openly.

Most nurses, doctors and pharmacists, however, still believe their institutions are more interested in punishing mistakes than in discovering why mistakes occur and using that information to create a safer patient environment.

These are the conclusions drawn from data recently collected by the AHRQ.

In their latest survey, 600,000 staffers at more than 1,100 hospitals were questioned. Half said they felt that “their mistakes are held against them,” according to a story in the Feb. 27 edition of the American Medical News. More than half also said they feel that there is more emphasis on the person who committed the error than on what might have contributed to the error.

The 2012 report also states that about 20 percent of hospitals surveyed have improved procedures for dealing with errors, but 16 percent have “worsened with time.” The remaining hospitals have neither improved nor worsened, and have a “similar pattern” as before when it comes to open communication.

According to the Joint Commission, hospital staffers should operate in an environment that is free of fear of disciplining, and should feel confident that problems of safety can be addressed with free communication. The only way to accomplish this, according to one expert, is to “just do it” – and make sure all employees know about it. This is the best way to develop trust and change the culture.

What do you think are the key factors in creating a culture of safety?

Have you had any experiences, good or bad, with reporting errors?

Tell us about it.

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