PMID- 33575159
OWN - NLM
STAT- PubMed-not-MEDLINE
LR  - 20210213
IS  - 2168-8184 (Print)
IS  - 2168-8184 (Electronic)
IS  - 2168-8184 (Linking)
VI  - 13
IP  - 2
DP  - 2021 Feb 7
TI  - Achieving and Maintaining Safety in Healthcare Requires Unwavering Institutional 
      and Individual Commitments.
PG  - e13192
LID - 10.7759/cureus.13192 [doi]
LID - e13192
AB  - In 2000, "To Err Is Human" brought to light the fact that the estimated number of 
      people dying from medical errors occurring in hospitals exceeded those that die 
      from motor vehicle accidents (MVAs), breast cancer, or acquired immunodeficiency 
      syndrome (AIDS) - three causes receiving far more public attention. The report 
      prompted the gradual adoption of safety processes developed in the nuclear and 
      aviation industries. However, sophisticated engineering solutions to operations 
      are not enough. High and low mortality hospitals have similar processes and 
      procedures, but low-mortality hospitals are more proficient at recognizing and 
      managing serious complications as they unfold. This ability to rescue a 
      deteriorating situation (resilience) reflects a healthier safety culture. 
      Organizations move within the safety space in the direction of either more or 
      less resilience depending on the fluctuation of their safety culture. Improving 
      resilience requires transforming learned safety practices into a "habit" in 
      conjunction with accepting accountability. Personal accountability means 
      commitment to safe practices along with effective and transparent reporting of 
      near misses/close calls and adverse events (AEs). Institutional accountability 
      means putting safety first by ensuring the availability of appropriate resources, 
      role leadership modeling, and effective management of sentinel events (SEs) to 
      reduce harm occurrence and re-occurrence. This requires a more robust root cause 
      analysis (RCA) process to guarantee that action plans produce strong and 
      effective corrective measures. Synergistic coaching interventions include 
      instilling the awareness that failure can and will happen, mapping team talents, 
      and assessing gaps. These interventions will optimize group expertise, 
      reaffirming the concept of institutional and personal accountability. The 
      unending performance of drills will sustain the group resilience under both 
      expected and unexpected conditions. Given the strong correlation between practice 
      environment and outcomes, sustained improvement of the safety climate will 
      produce more robust safety behaviors and ultimately better outcomes.
CI  - Copyright (c) 2021, Rigamonti et al.
FAU - Rigamonti, Daniele
AU  - Rigamonti D
AD  - Neurological Surgery, Johns Hopkins Medicine International, Johns Hopkins Health 
      System Corporation, Baltimore, USA.
FAU - Rigamonti, Karen H
AU  - Rigamonti KH
AD  - Medicine, Johns Hopkins Medicine International, Johns Hopkins Health System 
      Corporation, Baltimore, USA.
LA  - eng
PT  - Journal Article
PT  - Review
DEP - 20210207
PL  - United States
TA  - Cureus
JT  - Cureus
JID - 101596737
PMC - PMC7870115
OTO - NOTNLM
OT  - adverse events
OT  - close calls
OT  - coaching
OT  - harm
OT  - healthcare
OT  - medical errors
OT  - near misses
OT  - rca
OT  - safety
OT  - safety culture climate
COIS- The authors have declared that no competing interests exist.
EDAT- 2021/02/13 06:00
MHDA- 2021/02/13 06:01
PMCR- 2021/02/07
CRDT- 2021/02/12 06:08
PHST- 2021/02/12 06:08 [entrez]
PHST- 2021/02/13 06:00 [pubmed]
PHST- 2021/02/13 06:01 [medline]
PHST- 2021/02/07 00:00 [pmc-release]
AID - 10.7759/cureus.13192 [doi]
PST - epublish
SO  - Cureus. 2021 Feb 7;13(2):e13192. doi: 10.7759/cureus.13192.