La postura sobre la recomposición de la norma en relación a los sucesos

examples of organizational Behaviors values Practice Settings (i.e. Hospitals, Health

Systems, Physician organizations)

Physician Advocacy and Professional organizations

Fair and ethical stewardship of health care resources

• Encourage judicious use of resources to care for a patient population, eg, by providing information on system- level costs and outcomes

• Implement mechanisms for supporting cultural competency and continuous quality improvement focused on reducing disparities in care

• Advocate for development and adoption of tools to support cost-effective care and judicious use of health care resources

• Promote public health and advocate on behalf of societal interests with respect to health and health care, without concern for the self-interest of the individual physician or the profession

• Advocate for payment policies that drive a focus on total cost of care rather than discrete encounters and individual clinician inputs • Support development of tools to facilitate

reflection on disparities in care and drive down unwarranted variation

6. Just Culture of Patient Safety

Authors

Amy Nakajima, MD, FRCSC Sarah Taber, MHA/MGSS

Susan Brien, MD, MEd, CSPQ, FRCSC, CPE, FRCSC Mark Daly, RRT MA (Ed)

Chris Hayes, MD, FRCPC Mark Fleming, PhD Angèle Landriault, BScN Anne Matlow, MD, FRCPC Gary Victor, MD, FRCPC Gordon Wallace, MD, FRCPC Kenneth A. Harris, MD, FRCSC

ABStrACt

Patient safety is a cornerstone of quality health care. The provision of high-quality, safe health care goes beyond patient- and disease-specific diagnosis and management to demand the adoption and cultivation of a proactive systems perspective termed a “just culture” of patient safety. Canadian stakeholder organizations have long been concerned with patient safety, leading to the development of tools and resources intended to improve patients’ clinical outcomes. However, despite the quality of these initiatives, the authors’ experience suggests that their uptake remains minimal and inconsistent among postgraduate medical education (PGME) programs and that more work is needed to improve that uptake, ultimately ensuring health care systems are designed to deliver consistently safe care. Recognizing the importance of patient safety and the development of a culture of patient safety, this paper explores the possible reasons for the poor uptake of The Safety Competencies. In particular, the “hidden curriculum” has the ability to undermine the best efforts to implement a well-constructed and thoughtful formal patient safety curriculum. Subsequently, the authors also outline a series of recommendations for change, including a number of approaches for embedding patient safety into existing PGME curricula. These recommendations include increased teaching capacity, deliberate planning and creation of a patient safety curriculum, and developing teaching strategies and tools, as well as methods of assessment. Specific ways in which the Royal College can advance patient safety in specialty PGME include the following:

• enhanced articulation of patient safety

competencies in the next iteration of the CanMEDS Physician Competency

Framework;

• inclusion of patient safety knowledge,

skills and attitudes on the Royal College exams and as a mandatory component of Maintenance of Certification; and

• measurement of patient safety culture

as a PGME accreditation requirement.

Academic departments are urged to formally recognize teaching and research in patient safety and quality improvement, and leadership is encouraged to include patient safety in their academic missions, effectively promoting and advancing patient safety in the teaching and clinical environments within their organizations. Together, these elements would serve to demonstrate a collective commitment to establishing an articulated just culture of patient safety, which is essential if we hope to improve patients’ clinical outcomes by avoiding healthcare related harm.

IntroDuCtIon

Providing safe care goes beyond patient- and disease- specific diagnosis and management to demand a systems’ perspective that considers the nature and contribution of the organization, people, tasks, tools, technology and environment to patients’ clinical outcomes. Those organizations that truly embody a commitment to patient safety also foster a proactive and innovative culture that identifies and corrects vulnerabilities in the processes and systems of care rather than waiting to respond to adverse events.1 _{It is} important, as such, to focus on the development of a culture of patient safety. In this context, a “culture of patient safety” refers to

the commitment of health care practitioners and their institutions and organizations to minimize patient harm, promote the well-being of patients and health care providers, reduce the likelihood of adverse events, and communicate safety concerns – while at the same time learning from close calls and other events.2

There are principles and values that are common to a patient safety culture. For instance, a culture of patient safety values transparency,3 _{accountability,}4 _{and patient-} and family-centred care,5 _{and is one that learns from} adverse events, including errors and close calls (near misses). This culture is generative and that of a learning organization — one in which information is actively sought, failures and near misses result in inquiry, and new ideas are welcomed.6 _{In this type of culture, health} care workers are also provided with the opportunity to develop the knowledge, skills and attitudes to practise the safest medicine possible. Finally, a recent review generated a conceptual culture of safety model. In this work, seven subcultures of a patient safety culture were identified: leadership, teamwork, evidence-based, communication, learning, just and patient-centred.7 Admittedly, it is challenging to define, and to speak specifically about, culture in the context of a system as complex as health care. It is often said that “culture is the way we do things around here.”8 _{However, in health} care, there are a variety of locations within which patient care is provided and a variety of individuals by whom patient care is provided. As such, notions of both “we” and “here” are complex. The current patient safety research literature, and indeed this paper, recognizes that in terms of attitude, knowledge and uptake related to patient safety, each environment or unit will be unique.9

BACKGrounD

Patient safety, or the freedom from harm related to the provision of health care, is a cornerstone and key dimension of high-quality health care.10,11 _Current statistics regarding adverse events underline the need for continuous, rigorous improvements in patient safety throughout the Canadian health care system. Although no organization or health care professional intends to harm a patient, the reality is that the health care system is not yet designed to deliver consistently safe care.12 _{In Canada,} between 9,000 and 24,000 adults are injured every year in hospital as a result of adverse events.13 _{Similarly, a} recently published chart review identified that 9.2 per cent of children admitted to Canadian hospitals experience an adverse event.14

The occurrence of adverse events has devastating human and fiscal implications. It is important to see beyond the numbers and statistics outlined above. Each incident or event has happened to a person with a name and a face; the harm they experienced has an impact on them as a patient, as well as on their loved ones, the community and society as a whole. The fiscal cost of treating system- related adverse events is also significant.9 _{In an era of} increased expectations of accountability, such costs emphasize the importance of addressing, and improving, patient safety.

Recognizing the importance of improving patient safety in health care settings, stakeholders have long been concerned with patient safety in Canadian postgraduate medical education (PGME). However, to date, these initiatives have not seen comprehensive, national implementation. Evidence suggests that more work is needed to promote and advance a just culture of patient safety. The Future of Medical Education in Canada (FMEC) initiative provides an opportunity to bring patient safety to the forefront of PGME.

An overview of Patient