CASE STUDY

Case Study



Case Study

(a)

Over a decade ago, the Institute of Medicine (IOM) urged health care organizations to adopt proven organizational models and strategies from other high-risk industries to minimize error and reduce harm to patients.1 To promote a culture of safety and ensure safer systems of care, the IOM emphasized the importance of developing clear, highly visible patient safety programs that focus organizational attention on safety; use non-punitive systems for reporting and analyzing errors; incorporate well-established safety principles such as standardized and simplified equipment, supplies, and work processes; and establish proven interdisciplinary team training programs for providers (Ferlie, 2005).

The IOM also noted that, “the biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm”. By developing a “systems” orientation to understanding and addressing medical errors, hospitals can foster an organization-wide continuous learning environment where members of the workforce feel comfortable reporting and discussing adverse events without fear of reprisal (Hibbard, 2000).

In recent years, consensus has emerged among patient safety experts that cultural attributes such as leadership support, teamwork, communication, and fair and just culture principles remain central to achieving high reliability and ensuring patient safety in health care organizations.

(b)

Drew should adopt various measures to ensure perfect protection to the patients. This section discusses the hospital leaders (drew) to design various measures to implement healthcare safety for the patients. Hospital leaders face increasing pressure to cultivate an organizational culture of safety that protects patients from medical error. However, the definitional ambiguity and breadth of safety culture as a construct can make it difficult, if not daunting, to operationalised (McGlynn, 1998).

In developing the Culture Survey, AHRQ adopted the definition of safety culture used by the Health and Safety Commission of Great Britain: “The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.”

Reason and Hobbs suggest that rather than attempt a single comprehensive definition of patient safety culture, it is often more useful to think of safety culture in terms of three essential, interlocking attributes or components: (1) a just culture, (2) a reporting culture and (3) a learning culture.

They note that culture is further defined by what an organization is (beliefs, attitudes and values), as well as what an organization does (structures, practices, policies and controls). This interplay of beliefs, attitudes and values on the one hand and structures, practices, policies and controls on the other raises the question of whether changing culture is best addressed by changing beliefs or by modifying structures and ...