TO DO NO HARM

This book by Juliane Morath and Joanne Turnbill is like a handbook on patient safety. It offers 10 chapters that consistently drive home several key points and provide opportunities for lively conversation. The book also includes extensive references and resources about patient safety, a complete glossary, and 14 appendices. To Do No Harm1 discusses overall philosophy, concepts, and challenges related to the importance of patient safety in the healthcare arena and offers numerous ideas, suggestions, and tools for addressing various issues. The authors also throw in some new terms such as sharp-end and blunt-end workers.

One of the primary points made in relation to patient safety is that this is about building a culture, a way of thinking about systems that eliminates harm versus just looking at error reduction. The importance of leadership in establishing a culture that promotes patient safety is stressed over and over. First, the leader has to believe that harm-free care is achievable. One of the chapters includes at least 30 bullet points in a checklist for executive leaders who are establishing a patient safety agenda in their organization. These items range from available resources and videos, conversations and key people to involve, and communication and reporting strategies.

The authors share descriptions of cultures that facilitate safety. A generative culture is one that is open to new ideas and promotes storytelling. There is openness to hearing the truth and learning from mistakes and near misses. This culture avoids blaming. One of the challenges facing healthcare is the "silo" approach that has been the norm rather than a collaborative, interdisciplinary approach that looks at the issues from the viewpoint of all disciplines involved.

One of the terms that is used frequently by the authors is sharp-end workers. These workers are doing direct patient care work and are always weighing the probability of various outcomes of their actions. The blunt-end workers are management, regulators, suppliers, and payers. It is important for blunt-end workers to listen to sharp-end workers. Everyone has a voice in the world of patient safety.

The authors introduce the Swiss Cheese Model as a useful tool for looking at how a combination of multiple small failures can combine to form an accident by slipping through holes known as latent failures. These latent failures include mixed messages, attention distractions, and inadequate training, for example. Vulnerability is created as sharp-end workers "catch" and deflect failures before they reach patients. Healthcare professionals are masters at work-arounds for systems that do not work. However, high work loads, fatigue, and other sources of stress can cause slips, lapses, or mistakes that may result in accidents.

The discussion about error and harm in healthcare causes significant angst among providers, making the shift from person to process extremely important. The authors make a point about "hindsight bias" that tends to lay blame versus looking at variation in systems, communication, transitions, teamwork, and other factors. This makes a proactive rather than reactive approach to safety a key. The root cause analysis process lends itself to hindsight bias, whereas the failure mode and effects analysis (FMEA) process audit is more proactive.

A concept presented by the authors is that of high-reliability organizations (HROs) which are defined as organizations "in which failure is not an option, because lives are at stake." Workers in these organizations remain individually and collectively alert and prepared to deal with unforeseen events. Communication, risk acknowledgement, emphasis on learning, and mindfulness are all factors in HROs.

To build on the aspects of a culture that is open to learning and avoiding blame, such as a HRO, the authors describe and share a blameless reporting system. The willingness to review, analyze, and understand deviations, variances, dangerous situations, and near misses that occur and never make it to the surface as an accident truly helps to create a system that promotes safety. The mantra in these organizations is, "Fix what you can. Tell what you fixed. Find someone to fix what you cannot." It is all about communication, sharing, and learning.

The belief in telling the truth and disclosure as part of a safety culture is also addressed throughout the book. An entire chapter is devoted to protocol and policy development about focused event analysis. A case study is shared as an excellent example of handling a disclosure situation in a responsible, collaborative manner. The authors do an excellent job of giving specific tools, questions, and actions for handling the various components of building a culture around safety. One of these ideas is the safety action teams that are described in detail.

The authors point out that patient safety is more than a project and requires changing a whole system, not parts within it, which actually impacts the healthcare industry. This point highlights the importance of partnering with consumers, education, purchasers, and regulators. There are many organizations that support the patient safety initiative. These include the National Patient Safety Foundation, the National Center for Patient Safety, the Harvard Executive Sessions on Medical Error and Patient Safety, the National Quality Forum (NQF), the Leapfrog Group, the Institute of Medicine (IOM), the Agency for Healthcare Research and Quality (AHRQ), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and others.

The authors suggest it is the leader's role to enable effective teams to tackle safety issues, ask the difficult questions, and move the process forward. A table lists characteristics of slow and fast teams. Shared vision, commitment, focus, and connection to strategy are key factors to making significant change. Using performance improvement methodologies such as Six Sigma, and involving players such as risk managers, department managers, and physicians, is essential to creating best practice. Traditional efforts will not create patient safety-early adoption and innovative thinking are required.

Healthcare is clearly behind other industries in making safety a priority. This book identifies tools and mechanisms that other industries such as NASA and aviation have used that can be brought into the healthcare industry. In the last chapter, the authors share more than 15 lessons learned on their journey to creating patient safety, which are very insightful and helpful.

There are many audiences who might use this book. Certainly, those in healthcare organizations such as risk managers, patient safety officers, and leaders who are establishing patient safety cultures would benefit from using this book to facilitate conversation about philosophy and development of a culture that embraces safety. A patient safety committee could use this as a guide for establishing policies, reports, and agendas.

Nursing schools and health administration programs in colleges and universities could and should use this book as well. The chapters are written in a way to promote discussion through questions that are posed, case studies, and summary points at the end of the chapters. Medical schools could also benefit from an awareness of this topic.

There is not a "one size fits all" patient safety agenda, and the authors do an excellent job of offering a variety of ways to approach the process.

Reviewed by

Joy Gorzeman MBA, MSN, RN

Senior Vice President, Patient Care Services and, Chief Nursing Officer, Department of Clinical and, Physician Services, Trinity Health, Novi, Mich [email protected]

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