Building Safer Health Systems with RLDatix

Designing error out of the system: A collaborative, safety science approach to learning from avoidable harm

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At the HSJ Patient Safety Congress we spoke about the complexity of healthcare systems and how they are by nature, very high-risk. In order to make needed transformational change in healthcare, the change must begin with incremental steps at the individual level. However, for individuals to feel comfortable, leadership must encourage environments that allow people to own mistakes and errors without fear of being individually blamed. The healthcare industry can learn from other “high-hazard” industries (like airlines) by shifting to a culture that instantly assumes errors are rooted in a system failure, instead of individual culpability. Shifting to this institutional mindset of shared responsibility encourages learning from adverse health events and empowers workforces to influence changes in processes and procedures to keep organisations safer.

Building a safer system

Change is emotionally expensive. By approaching change with empathy and a true understanding of a local workforce, individual leaders can relieve much of the fear associated with change and instill a culture of continuous improvement.

Workforces should collaborate inter-departmentally to build a safer organisation by considering what is important to change, and then determining together the best way to begin making changes. Healthcare systems are built to believe that people matter more than anything else – and this must extend not only to patients and caregivers but also to the workforces that support them. Trust must be consistent across departments so individual staff members believe their independent voices and actions have the power to impact change. Curating a culture where individuals are both independently looking to improve themselves while also looking to truly help their colleagues improve leads to a highly responsible and highly reliable culture, which is a breeding ground for positive change. Small incremental changes are transformational, and transformational changes occur because of human buy-in. By nurturing a psychologically safe environment that values compassionate leadership, a willingness to listen to problems and the opportunity to speak truth to people in positions of power, healthcare organisations can build better cultures.

The biggest correlation related to healthcare systems’ mortality rates is their culture, and culture is free to those willing to be open and learn from their workforce, patients and caregivers.

A note to healthcare leaders

Be emotional. Be understanding. Be empathetic. Demonstrate transparency and care for your people. Remind your staff that you believe each individual can affect change that will make patients safer, your workforce safer, and ultimately, the entire organisation safer.

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