Improving Patient and Worker Safety

Improving Patient

and Worker Safety

Opportunities for Synergy, Collaboration and Innovation

Improving

Patient and Worker

Safety

Opportunities for Synergy, Collaboration and Innovation

The Joint Commission Mission

The mission of The Joint Commission is to continuously

improve health care for the public, in collaboration with other

stakeholders, by evaluating health care organizations and

inspiring them to excel in providing safe and effective care of

the highest quality and value.

Disclaimer

This monograph was developed under a project supported in

part by the National Institute for Occupational Safety and

Health (NIOSH), National Occupational Research Agenda

(NORA), Healthcare and Social Assistance Sector Program,

under contract no. 212-2010-M-35609. The goal of the proj-

ect is to stimulate greater awareness of the potential syner-

gies between patient and worker health and safety activities.

This monograph is designed to introduce concepts and topics

but is not intended to be a comprehensive source of all rele-

vant information relating to patient and worker safety topics

and resources in health care settings. The monograph is not

designed to provide guidance on compliance with OSHA reg-

ulations, state legislative requirements, or Joint Commission

standards. Readers should refer to the source documents

listing requirements from the respective organizations for

guidance on compliance issues. Similarly, recommendations

for practice described herein should not be construed as pol-

icy or practice recommendations from The Joint Commission.

Although many suggestions and recommendations are

derived from literature and consensus, they should not nec-

essarily be considered evidence-based because of the limited

amount of rigorous research in this area.

The content and recommendations are solely the responsi-

bility of the Joint Commission project staff and others who

contributed material. We have worked to ensure that this

monograph contains useful information, but this monograph

is not intended to be a comprehensive source of all rele-

vant information. In addition, because the information con-

tained herein is derived from many sources, The Joint

Commission cannot guarantee that the information is com-

pletely accurate or error-free. The Joint Commission is not

responsible for any claims or losses arising from the use

of, or from any errors or omissions in, this monograph.

Permission to reproduce this guide for noncommercial, edu-

cational purposes with displays of attribution is granted. For

other requests regarding permission to reprint, please call

Hasina Hafiz at 630-792-5955.

Printed in the USA 5 4 3 2 1

Suggested citation

The Joint Commission. Improving Patient and Worker Safety:

Opportunities for Synergy, Collaboration and Innovation.

Oakbrook Terrace, IL: The Joint Commission, Nov 2012.

http://www.jointcommission.org/.

For more information about The Joint Commission, please

visit http://www.jointcommission.org.

Joint Commission Project Staff

Barbara Braun, PhD

Project Director

Department of Health Services Research

Division of Healthcare Quality Evaluation

Annette Riehle, RN, MSN

Project Consultant, Writer

Department of Health Services Research

Division of Healthcare Quality Evaluation

Kris Donofrio

Project Coordinator

Division of Healthcare Quality Evaluation

Hasina Hafiz, MPH

Research Associate

Department of Health Services Research

Division of Healthcare Quality Evaluation

Jerod M. Loeb, PhD

Executive Vice President

Division of Healthcare Quality Evaluation

Joint Commission Resources

Editorial and Production Support

Kristine M. Miller, MFA

Executive Editor

Department of Publications and Education Resources

Christine Wyllie, MA

Senior Project Manager, Production

Department of Publications and Education Resources

iii
Contents
Front matter (Disclaimer, Acknowledgements, List of Expert Advisors, and Project Team) ....ii, vi
Foreword ..................................................................................................vii
Paul M. Schyve, MD, Senior Advisor, Healthcare Improvement, The Joint Commission
Introduction ..............................................................................................1
Monograph purpose............................................................................................................................1
Monograph parameters ......................................................................................................................2
Target audience ..................................................................................................................................2
Roundtable project overview ..............................................................................................................2
References ........................................................................................................................................3
Chapter 1: High Reliability in Health Care Organizations and 
Benefits to Improving Safety for Both Patients and Workers ................7
1.1 What is a high reliability organization? ........................................................................................7
1.2 High reliability in health care ........................................................................................................8
1.3 The importance of a safety culture ..............................................................................................9
1.4 Why high reliability requires attention to both patient and worker safety ..................................11
1.5 Potential benefits to improving safety for patients, staff, and organizations and return on 
investment (ROI) considerations ......................................................................................................11
Case Study 1-1: Building a high reliability culture for patients and health care workers: 
St. Vincent’s Medical Center, Bridgeport, Connecticut..............................................................15
References ......................................................................................................................................18
Resources 1-1: Examples of safety culture surveys ........................................................................19
Resources 1-2: Resources related to models for demonstrating value ..........................................22
Chapter 2: Management Principles, Strategies, and Tools That 
Advance Patient and Worker Safety and Contribute to High 
Reliability ................................................................................................25
2.1 Safety management systems: common elements for workers and patients..............................26
2.1.1 Civility in the workplace....................................................................................................27
Case Study 2-1: US Department of Veterans Affairs: Building a culture of civility in the 
workplace—civility, respect, and engagement in the workplace........................................27
2.2 Hierarchy of controls: example of a framework for interventions to prevent harm ....................34
2.3 Human factors and safer design ................................................................................................35
2.3.1 Human factors ..................................................................................................................36
2.3.2 Ergonomics ......................................................................................................................36
2.3.3 Safer design of work processes ......................................................................................38
2.3.4 Preventing harm through safer design of the built environment ......................................38
2.4 Improving performance through incident reporting and feedback systems ..............................40
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Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation
Resources 2-1: Human factors and safer design......................................................................41
2.4.1 Sources for outcome dat
a on worker and patient safety ................................................44
2.4.2 Incident surveillance, reporting, analysis, and feedback..................................................45
2.4.2.1 Examples of injury and illness tracking systems for workers and patients............46
2.5 Selected strategies and tools for improving safety ....................................................................47
2.5.1 Leadership strategies ......................................................................................................47
2.5.1.1 Tell real stories ......................................................................................................48
2.5.1.2 Conduct leadership rounds ....................................................................................48
Case Study 2-2: Duke Home Care: Focusing on safety in home care–
the Director Safety Rounds Program..........................................................................48
2.5.2 Management strategies to support staff engagement in improving patient and 
worker safety ............................................................................................................................50
2.5.2.1 Provide training, time and resources ....................................................................51
2.5.2.2 Recognize or reward all efforts ..............................................................................51
2.5.2.3 Utilize frontline safety coaches, champions, and unit peer leaders ......................51
2.5.2.4 Analyze feedback and findings from patient and worker satisfaction surveys 
to identify opportunities for improvement ..........................................................................51
2.5.3 Tools to enhance communication ....................................................................................51
2.5.3.1 Daily huddles..........................................................................................................51
2.5.3.2 Phrase to signal concern and demand attention ..................................................52
2.5.3.3 Teach back or repeat back ....................................................................................52
2.5.3.4 Situation-Background-Assessment-Recommendation (SBAR) communication 
and SHARE ........................................................................................................................52
2.5.4 Tools for risk or hazard identification and adverse event or incident analysis ................52
2.5.4.1 Failure modes and effects analysis (FMEA) ..........................................................53
2.5.4.2 Fault tree analysis ..................................................................................................53
2.5.4.3 Tracer methodology for safety events....................................................................53
2.5.4.4 Root cause analysis (RCA)....................................................................................53
References ......................................................................................................................................54
Resources 2-2: General resources on leadership and work environment ........................59
Chapter 3: Specific Examples of Activities and Interventions 
to Improve Safety ....................................................................................61
3.1 Musculoskeletal injuries and accidents ......................................................................................62
3.1.1 Safe patient handling........................................................................................................62
3.1.1.1 Impact on patients and workers ............................................................................62
3.1.1.2 Examples of interventions ......................................................................................65
Resources 3-1: Safe patient handling................................................................................66
Case Study 3-1: Lancaster: Voluntary Protection Program: Commitment to 
bariatric patient safety ................................................................................................68
Case Study 3-2: Intermountain Healthcare: An integrated employee and 
patient safe handling program ....................................................................................71
3.1.2 Slip, Trip, and Fall ............................................................................................................72
3.1.2.1 Impact on workers and patients ............................................................................74
3.1.2.2 Examples of interventions ......................................................................................74
Resources 3-2: Slips, trips, and falls..................................................................................76
Case Study 3-3: Kaiser Permanente: Simple steps improve safety—a slip, trip, 
fall (STF) prevention measure ....................................................................................76
3.2 Sharps injuries and infection transmission ................................................................................78
3.2.1 Sharps injuries and bloodborne pathogen exposures......................................................78
3.2.1.1 Impact on patients and workers ............................................................................78
3.2.1.2 Examples of interventions ......................................................................................79
3.2.1.2.1 Safe injection practices: The CDC’s “One and Only” campaign..................80
3.2.2 Preventing transmission of infectious diseases ..............................................................80
Resources 3-3: Sharps injuries ..........................................................................................81
3.2.2.1 Impact on patients and workers ............................................................................83
3.2.2.2 Examples of interventions ......................................................................................83
iv

Contents
3.3 Exposure to hazardous substances ..........................................................................................84
3.3.1 Hazardous drugs, chemicals, and other subst
ances ......................................................84
Resources 3-4: Prevent infection transmission..................................................................86
3.3.1.1 Impact on patients and workers ............................................................................88
3.3.1.2 Safe drug handling examples ................................................................................88
3.3.1.3 Safe disposal of hazardous drugs or waste ..........................................................89
3.3.1.4 Survey of health care worker extent and exposure to hazardous chemical 
agents ................................................................................................................................89
3.3.2 Radiation ..........................................................................................................................89
3.3.2.1 Impact on staff and patients ..................................................................................89
3.3.2.2 Examples of interventions ......................................................................................91
Resources 3-5: Hazardous drugs and substances ............................................................92
3.4 Violence in the health care setting ............................................................................................95
3.4.1 Assaults and violence prevention and management, security ........................................95
3.4.1.1 Impact on patients and workers ............................................................................95
Resources 3-6: Radiation ..................................................................................................96
3.4.1.2 Examples of interventions ......................................................................................99
Resources 3-7: Assaults and violence ............................................................................102
Case Study 3-4: Lemuel Shattuck Hospital: Reducing assaults in a behavioral 
health unit..................................................................................................................104
Case Study 3-5: Atlantic Health: Securing a health system red cell program ..........107
Case Study 3-6: Veterans Health Administration (VHA): Reducing disruptive 
patient behavior: The behavioral threat management program................................108
3.5 Staffing, fatigue, and support for health care–induced emotional distress ..............................111
3.5.1 Workforce staffing and fatigue ........................................................................................111
3.5.1.1 Impact on patients and workers............................................................................111
3.5.1.2 Examples of interventions ....................................................................................112
Resources 3-8: Workforce staffing and fatigue ................................................................116
3.5.2 Work-related emotional injuries and illness....................................................................117
3.5.2.1 Impact on patients and workers ..........................................................................117
3.5.2.2 Examples of interventions ....................................................................................118
Case Study 3-7: University of Missouri: Caring for Our Own: Clinician support 
following unanticipated clinical events ......................................................................119
References ....................................................................................................................................123
Resources 3-9: Work-related emotional injury ................................................................124
Chapter 4: Patient and Worker Safety Synergies—Key Themes and 
Action Steps to Meet Challenges and Achieve Success ....................131
4.1 Future research and activities ..................................................................................................131
4.2 Conclusion ................................................................................................................................133
Appendix A: OSHA Topics Matched to Joint Commission Standards....135
Appendix B: Glossary of Terms ............................................................139
Appendix C: Description of Selected OSHA Standards Relevant to 
Health Car
e............................................................................................147
Index ......................................................................................................149
v

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Acknowledgments

The Joint Commission project team is sincerely appreciative

of the many individuals and organizations that contributed

to this monograph during the various stages of the project.

Though we are sure to miss some, the project staff would

like to specifically acknowledge the contributions of several

groups and persons.

We are grateful to the National Institute for Occupational

Safety and Health (NIOSH), National Occupational

Research Agenda (NORA), Healthcare and Social Assistance

Sector Council who enthusiastically supported the initiative

from its inception to its conclusion. In particular, we wish

to thank Eileen Storey, MD, MPH for serving as co-chair of

the Council and as Project Officer for this initiative and for

her exceptional wisdom and steady guidance of the project.

David Weissman, MD; Teri Palermo, RN, BSN; and James

Boiano, MS, CIH also were instrumental in moving this

forward and a great pleasure to work with.

During the process of identifying and reviewing case studies as

well as reviewing and improving the monograph content, we

were privileged to work with several nationally and interna-

tionally recognized experts, including David M. DeJoy, PhD;

Michael J. Hodgson, MD, MPH; Melissa A. McDiarmid,

MD, MPH, DABT; and Nicholas Warren, ScD, MAT.

Their willingness to volunteer substantial time and effort to

this project clearly demonstrates their sincere commitment

to improving patient and worker safety on a broad scale.

Many health care organizations submitted examples of effec-

tive practices, only a small proportion of which are high-

lighted in this monograph. We are grateful to those

providers and health care workers in the field who were will-

ing to share their creative ideas for the roundtable meeting

and this monograph, including Corey Bain, MPH, CSP,

CHMM, CIE, CPEA, REA; Maureen Cash, PhD; Marlyn

Conti, RN, BSN, MM; Kerry Eaton, RN, MS; Bobbi Jo

Hurst, RN, BSN, COHN-S; LaVerne Mullin, MPA, RN,

CPHQ; Susan D. Scott, RN, MSN; Joel Skolnick, MSW,

and Alan Robinson.

Several technical reviewers and content experts contributed

their knowledge and expertise to this publication. In addi-

tion to the persons named above, we would like to acknowl-

edge the contributions of John Decker, RPh, CIH; James

Collins, PhD, MSME; Daniel Hartley, EdD; Claire Caruso,

PhD, RN; Thomas Conner, PhD; Walter Alarcon, MD,

MSc; and Ahmed Gomaa, MD, ScD, MSPH.

Last, but definitely not least, many individuals from The

Joint Commission contributed substantial time and effort to

convening the roundtable meeting and developing, review-

ing, and producing the monograph. From the Division of

Healthcare Quality Evaluation we wish to thank John

Fishbeck, BS; Linda Kusek, RN, BSN, MPH, CIC; Cheryl

Richards, LPN, BS, RHIA; Gerry Castro, MPH; Tasha

Mearday; Scott Williams, PsyD; and Richard Koss, MA.

Expert Advisors

James Boiano, MS, CIH

Senior Industrial Hygienist, Surveillance Branch

Division of Surveillance, Hazard Evaluations and Field Studies

Centers for Disease Control and Prevention

National Institute of Occupational Safety and Health

David M. DeJoy, PhD

Professor Emeritus, Health Promotion and Behavior

University of Georgia

Department of Health Promotion and Behavior

College of Public Health

Melissa A. McDiarmid, MD, MPH, DABT

Professor of Medicine and Director,

University of Maryland Occupational Health Program

University of Maryland, School of Medicine

Eileen Storey, MD, MPH

Chief, Surveillance Branch

Division of Respiratory Disease Studies

Centers for Disease Control and Prevention

National Institute of Occupational Safety and Health

Nicholas Warren, ScD, MAT (Facilitator)

Associate Professor of Medicine, Ergonomics Coordinator

School of Medicine and Occupational and Environmental

Health Center, and Ergonomic Technology Center

University of Connecticut Health Center

Annalee Yassi, MD, MSc, FRCPC

Professor, Faculty of Medicine

The University of British Columbia School of Population

and Public Health

vii

Foreword

Safety is avoiding both short- and long-term harm

to people resulting from unsafe acts and preventable

adverse events. This definition does not differentiate

among patients, their families, staff and licensed

independent practitioners, visitors, vendors and

contractors, or anyone else within a health care set-

ting. And yet, many health care organizations have

“siloed” safety programs, creating one for patients,

another for workers, and yet another for others who

may be at risk. These siloed programs are usually

also administered separately—by clinical, human

resource, and general liability personnel, respec-

tively—and the information and solutions these

programs generate are not shared among them.

What a loss!

This monograph demonstrates why these different

safety programs should not—indeed, cannot—be

separated. The organizational culture, principles,

methods, and tools for creating safety are the same,

regardless of the population whose safety is the

focus. In fact, the same principles, methods, and

tools may be separately used by different groups

(clinical, human resource, and general liability per-

sonnel) within an organization. But it is not possi-

ble to generate and maintain a culture of safety that

encompasses only one or two of these groups. A cul-

ture of safety comprises trust in being treated justly

when an adverse event (or close call) occurs and is

reported; the obligation and willingness to report

adverse events and near misses; and reliable, effec-

tive improvement in response to the reports.

However, a culture of safety—and the organization

leaders who create and sustain it—will not be con-

sidered legitimate and genuine if the culture

excludes some groups within the organization. And,

if an organization’s culture of safety is not consid-

ered legitimate and genuine, it will not be valued

and accepted—nor will it facilitate improved safety

throughout the organization.

But the need to create an organizationwide culture of

safety is not the only reason for breaking down the

barriers between patient safety and worker safety. As

the chapters and case studies herein demonstrate, haz-

ards, close calls, and adverse events that affect one

group (patients) may bring to light risks that will also

endanger another group (workers), since the underly-

ing causes—and, therefore, solutions—are often the

same. Failure to share the learning that occurs in dif-

ferent contexts (within different groups and in differ-

ent sites) compromises an organization’s ability to

efficiently and effectively improve safety for all those

within the organization.

Although the reader may be personally invested in

achieving the synergy between patient safety and

worker safety activities that is described in this

monograph, often, enlisting others in the cause is

the first step in helping an organization change.

And convincing others is often as dependent on the

story told as on the facts presented. The story gives

the facts meaning. The extensive case studies pre-

sented here tell the story, not just the facts.

Therefore, they do more than merely demonstrate

how the safety programs in an organization can be

integrated. They also explain why these programs

should be seamlessly woven together.

One often hears concerns about the “return on invest-

ment”—the ROI—of patient safety activities. Their

resource use may be great, but their financial return is

difficult to measure. The same can be said about

investment in staff safety. But the value of any invest-

– ● –

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

ment should be related to its business case, which is not lim-

ited to the financial ROI. The business case for any activity

includes the following three components:

1. The activity’s contribution to achieving the organiza-

tion’s mission(s)

2. The activity’s contribution to stakeholders’ (patients,

staff) satisfaction

3. The activity’s contribution to the bottom line (the

ROI).

All these components are relevant, and no one component

alone determines the value of the investment in an activ-

ity. Activities to improve safety are strong contributors to

#1 and #2, and being efficient and effective in conducting

these activities contributes to #3—the ROI. The integra-

tion and synergy described in this monograph can con-

tribute to the efficiency and effectiveness of safety-related

activities.

In health care, the primary ethical imperative is “First, do

no harm.” Although we have traditionally applied this obli-

gation to our patients, this monograph helps to establish it

also as our obligation to those with whom we work—and to

all within the health care setting.

viii

Paul M. Schyve, MD

Senior Advisor

Healthcare Improvement

The Joint Commission

Introduction

ealth care professionals whose focus is on patient safety are very familiar

with these alarming and frequently cited statistics: Medical errors result in

the death of between 44,000 and 98,000 patients every year.

First released

in the 1999 landmark report by the Institute of Medicine, To Err Is

Human, Building a Safer Health System, these numbers captured the attention of health

care leaders and spearheaded a widely publicized patient safety movement over the past

two decades. That movement continues today.

Health care professionals whose focus is on occupational health and safety, however, are likely aware of additional

statistics that are less well known: Health care workers experience some of the highest rates of nonfatal occupational

illness and injury—exceeding even construction and manufacturing industries.

2,3

Furthermore, a recent report based

on health care claims data indicates that hospital workers have higher health risks and are more likely to be diag-

nosed and hospitalized for chronic medical conditions.

What do these statistics tell us about safety for both patients and workers in the health care environment? Is there a

connection between worker safety and patient safety? Are there synergies between the efforts to improve patient

safety and efforts to improve worker safety? According to Merriam-Webster, synergy is a mutually advantageous

conjunction or compatibility of distinct business participants or elements.

How can improvement efforts be coor-

dinated for the benefit of all?

This monograph will explore these pressing issues.

Monograph Purpose

This monograph is intended to stimulate greater awareness of the potential synergies between patient and worker

health and safety activities. It will describe a range of topic areas and settings in which synergies exist between

patient safety and worker health and safety activities. The monograph will also describe the importance of safety

culture and why high reliability organizations are concerned with safety for both patients and health care workers.

In addition, the monograph will do the following:

• Highlight examples of health care organization practices that address patient and worker safety simultaneously

and the benefits and potential cost savings attained through collaboration between employee and patient safety

departments.

• Identify structural and functional management systems and processes that have been used to successfully inte-

grate health and safety activities.

– ● –

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

• Describe barriers to recognizing and addressing patient

and worker safety issues and suggest strategies for over-

coming the barriers by making safety a priority.

• Recommend action steps that health care organizations

can take to improve safety for both patients and workers.

• And, finally, the monograph will identify topics for

future research.

You will also find examples of resources for additional infor-

mation at the end of sections.

Monograph Parameters

This monograph is designed to bridge safety-related con-

cepts and topics that are often siloed within the specific dis-

ciplines of patient safety/quality improvement and

occupational health and safety. Toward that end, there are

occasional differences in terminology that are addressed

directly in the text or the glossary. One overarching seman-

tic issue relates to the term safety. The occupational health

field distinguishes between safety and health such that

worker safety refers to injury prevention, and worker health

refers to disease prevention and health promotion.

By con-

trast, within the patient safety field, the short-term and

long-term health effects on patients associated with unsafe

acts and events are included by implication within the term

patient safety. For the purpose of the monograph, the use of

the term safety will include short-term and long-term health

effects for both workers and patients.

The monograph is not intended to be a comprehensive

source of all relevant information relating to patient and

worker safety topics and resources in health care settings.

Many of the examples in this monograph come from self-

reported methods, tools, and data submitted by health care

organizations for a roundtable meeting on synergies between

patient and worker safety, which was held July 26, 2011,

and included representatives from leading health care safety

organizations. The examples also derive from published lit-

erature.

The monograph is not designed to provide guidance on

compliance with OSHA regulations, state legislative require-

ments, or Joint Commission standards. Readers should refer

to the source documents listing requirements from the

respective organizations for guidance on compliance issues.

Similarly, recommendations for practice described herein

should not be construed as policy or practice recommenda-

tions from The Joint Commission. The content and recom-

mendations are solely the responsibility of The Joint

Commission project staff and others who contributed mate-

rial. As described in Chapter 4, although many suggestions

and recommendations are derived from literature and con-

sensus, they should not be considered evidence based

because of the limited amount of rigorous research in this

area.

Target Audience

The information provided herein addresses a wide range of

health care organizations across settings and services. It will

be of interest to anyone in health care organizations

involved with patient and worker safety, including but not

limited to the following: administrative and clinical leaders,

quality improvement professionals, infection preventionists,

risk managers, occupational health practitioners, environ-

mental health and safety staff, patient safety staff, financial

planners, and human resource personnel.

Roundtable Project Overview

Based on the notion that high reliability health care organ-

izations are focused on safety for both patients and health

care workers, The Joint Commission undertook a project

to identify and disseminate examples of effective practices

that integrate safety-related activities. These examples,

which span health care settings, improve processes and

outcomes for both patients and health care workers. This

project was supported in part by the National Institute for

Occupational Safety and Health (NIOSH), National

Occupational Research Agenda (NORA), Healthcare and

Social Assistance Sector Program, under contract no. 212-

2010-M-35609.

The first step was to conduct a national call to solicit effec-

tive worker/patient safety practices in a wide range of rele-

vant topics. These topics included, but were not limited to

the following: worker and patient safety culture, worker and

patient satisfaction, injury prevention, infection prevention,

performance improvement, and individual engagement in

safety activities. The Joint Commission conducted this call

in the last quarter of 2010. More than 35 submitted prac-

tice examples were reviewed by a subgroup of the NORA

Healthcare and Social Assistance Sector Council to identify

examples not only from a variety of topic areas but also

from a range of health care settings. Criteria for selection

included practices with evidence of effectiveness; practices

that likely integrate leadership and functional responsibility

for safety training, surveillance, and management systems;

and practices likely to improve safety and/or outcomes for

both workers and patients.

Introduction

The next step was to convene a one-day invitational round-

table meeting comprising thought leaders and high-

performing health care organizations. The goal of the

roundtable was to identify key concepts and topic areas

highlighting the overlap and complementary nature of

patient safety and worker health and safety activities. The

information gained at the roundtable meeting, held on

July 26, 2011, at The Joint Commission headquarters in

Oakbrook Terrace, Illinois, became the foundation for this

monograph. Several of the submitting organizations were

invited to attend the invitational roundtable and selected

practice examples are included as case studies here (see

Table I-1 on pages 4–5).

References

1. Committee on Quality of Health Care in America, Institute of

Medicine. To Err Is Human: Building a Safer Health System.

Kohn L, Corrigan J, Donaldson M, editors. Washington, DC:

The National Academies Press; 2000.

2. US Department of Health and Human Services, Centers for

Disease Control and Prevention, National Institute for

Occupational Safety and Health [Internet]. State of the Sector |

Healthcare and Social Assistance: Identification of Research

Opportunities for the next Decade of NORA. DHHS (NIOSH)

Publication Number 2009-139. Available from:

http://www.cdc.gov/niosh/docs/2009-139.

3. U.S. Department of Labor [Internet]. Washington (DC);

[updated 2011 Oct 18; cited 2012 Jan 30]. Statement from

Secretary of Labor Hilda L. Solis on reported decline in workplace

injuries and illnesses, Release Number: 11-1547-NAT; [about 1

screen]. Available from: http://www.dol.gov/opa/media/press

/osha/OSHA20111547.htm.

4. Thomson Reuters [Internet]. Ann Arbor (MI): Thomson Reuters;

c2011 [updated 2011 Aug; cited 2012 Jan 30]. Sicker and

Costlier: Health care Utilization of U.S. Hospital Employees;

[about 6 p.]. Available from: http://img.en25.com/Web

/ThomsonReuters/H_PAY_EMP_1108_10237_HHE_Report

_WEB.PDF.

5. Merriam-Webster [Internet]. Merriam-Webster, Inc.; c2012 [cited

2012 Jan 31]. Definition of SYNERGY; [about 2 screens].

Available from: http://www.merriam-webster.com/dictionary

/synergy.

6. Levy BS, Wegman DH, Baron SL, Sokas RK. Occupational and

Environmental Health: Twenty-first Century Challenges and

Opportunities. In: Levy BS, Wegman DH, Baron SL and Sokas

RK, editors. Occupational and Environmental Health:

Recognizing and Preventing Disease and Injury. New York:

Oxford University Press; 2011. p. 5.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Table I-1: Roundtable Meeting Participants

Invited Experts

Roy Bethge

Sergeant

Buffalo Grove Police Department

Buffalo Grove, IL

[email protected]

James Boiano, MS, CIH

Senior Industrial Hygienist, Surveillance Branch

Division of Surveillance, Hazard Evaluations and

Field Studies

National Institute for Occupational Safety and Health

Centers for Disease Control and Prevention

Cincinnati, OH

[email protected]

David M. DeJoy, PhD

Professor Emeritus

University of Georgia

Department of Health Promotion & Behavior

College of Public Health

Athens, GA

[email protected]

Melissa A. McDiarmid, MD, MPH, DABT

Professor of Medicine and Director,

University of Maryland Occupational Health Program

University of Maryland, School of Medicine

Baltimore, MD

[email protected]

Eileen Storey, MD, MPH

Chief, Surveillance Branch

Division of Respiratory Disease Studies

National Institute for Occupational Safety and Health

Centers for Disease Control and Prevention

Morgantown, WV

ES[email protected]

Nicholas Warren, ScD, MAT

Associate Professor of Medicine, Ergonomics Coordinator

School of Medicine and Occupational and Environmental

Health Center, and Ergonomic Technology Center

University of Connecticut Health Center

Farmington, CT

[email protected]

Annalee Yassi, MD, MSc, FRCPC

Professor, Faculty of Medicine

The University of British Columbia School of Population and

Public Health

Vancouver, BC Canada

Annalee.Y[email protected]

Submitting Health Care Organizations at Meeting

Corey Bain, MPH, CSP, CHMM, CIE, CPEA, REA

National Environmental Health & Safety Senior Consultant

Kaiser Permanente

Oakland, CA

Corey[email protected]

Maureen Cash, PhD

Supervisory Program Analyst

Veterans Health Administration National Center for

Organization Development

Cincinnati, OH

[email protected]

Marlyn Conti, RN, BSN, MM

Quality & Patient Safety Coordinator

Quality/Patient Safety

Intermountain Healthcare

Salt Lake City, UT

[email protected]

Kerry Eaton, RN, MS

Senior Vice President

Chief Operating Officer

St. Vincent's Medical Center

Bridgeport, CT

[email protected]

Michael J. Hodgson, MD, MPH

Director, Occupational Safety and Health Program

Veterans Health Administration

Washington, DC

[email protected]

Bobbi Jo Hurst, RN, BSN, COHN-S

Manager, Employee and Student Health

Lancaster General Hospital

Lancaster, PA

[email protected]

Introduction

Table I-1: Roundtable Meeting Participants (continued)

Submitting Health Care Organizations at Meeting (continued)

LaVerne Mullin, MPA, RN, CPHQ

Director of Accreditation and Compliance, Patient Safety

Officer

Duke HomeCare & Hospice

Durham, NC

[email protected]

Susan D. Scott, RN, MSN

Patient Safety Coordinator

University of Missouri Health Care

Columbia, MO

[email protected]

Joel Skolnick, MSW

Chief Operating Officer

Metro Boston Mental Health Units (MBMHU), Lemuel

Shattuck Hospital

Jamaica Plain, MA

[email protected]

Observers/Participants

Dave Heidorn, JD

Manager, Government Affairs and Policy

American Society of Safety Engineers

Des Plaines, IL

[email protected]

Susan Kaplan, JD

Research Assistant Professor

School of Public Health/Institute for Environmental Science

and Policy

Director, Health Care Research Collaborative

University of Illinois at Chicago

2121 W. Taylor St. (MC 922)

Chicago, IL 60612

312-355-0738

[email protected]

Peter Orris, MD, MPH

Professor and Chief of Service

Occupational and Environmental Medicine (MC684)

University of Illinois at Chicago Medical Center

Chicago, IL

[email protected]

Joanne Velardi

Director of Occupational Health, Wellness and Rehabilitative

Services

St. Vincent's Medical Center

Bridgeport, CT

[email protected]

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

High Reliability in Health Care

Organizations and Benefits to

Improving Safety for Both

Patients and Workers

– Chapter 1 –

his chapter makes the case that high reliability health care organizations

should be intensely concerned with safety for both patients and workers. It

describes the importance of a safety culture and discusses the potential value

of investing in both patient and worker safety. The chapter also provides a

case example of leading-edge practices that actively integrate patient and worker safety

in pursuit of high reliability.

1.1 What Is a High Reliability Organization?

High reliability organizations (HROs) have been described as “systems operating in hazardous conditions that have

fewer than their fair share of adverse events.”

1(p.769)

Outside of health care, examples of industries or organizations often

considered to be highly reliable are nuclear power, aircraft carriers, and air traffic control. According to Reason, one of

the most important distinguishing features of HROs is their intense concern (often referred to in the literature as “pre-

occupation”) with the possibility of failure.

They recognize the inherent fallibility in humans as well as the risk of sys-

tem failure associated with equipment and devices used in tightly inter-related (coupled) work processes. HROs strive

to create systems and processes that prevent errors or mitigate their impact. They value identifying and reporting

potential and actual problems and treat adverse occurrences as opportunities for learning and improvement.

Weick

and colleagues describe the following five organizational culture characteristics that contribute to a “collective mindful-

ness” regarding error prevention: (1) preoccupation with failure, (2) reluctance to simplify interpretations, (3) sensitiv-

ity to operations, (4) commitment to resilience, and (5) under-specification of structures (see Figure 1-1, page 8). This

mindfulness requires both constant awareness and willingness to take action on the part of all staff.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Henriksen et al applied the Weick organizational culture

characteristics to activities relevant to nurses and other

health care workers (see Table 1-1, page 9).

1.2 High Reliability in Health Care

A well-known definition of reliable is “giving the same

result on successive trials.”

However, the same result is

not necessarily the correct result (as exemplified by a yard-

stick that is only two feet long). In health care and other

industries, the term reliability typically encompasses both

getting the same result and getting the correct result. For

example, the Institute for Healthcare Improvement (IHI)

defines reliability in health care as “failure-free operation

over time.”

Reliability can be calculated as the inverse of

the failure or defect rate. For example, if a process such as

timely administration of antibiotic fails 1 in every 10

cases, the failure rate is 10

-1

or 10%, and the reliability is

90%. By comparison, Six Sigma levels of reliability (the

same as six standard deviations) refer to processes that fail

no more than 3.4 times over a million opportunities (3.4

defects per million units): In other words, a 0.00034%

failure rate means the process is 99.966% reliable.

Six

Sigma levels of reliability are typically achieved in the air-

line and credit card industries but very rarely in health

care. However, one often-cited health care example is the

death rate associated with anesthesia, which has been

reduced to Six Sigma levels of reliability by concerted

attention to safety over several decades by the Anesthesia

Patient Safety Foundation and related groups.

Amalberti

et al. describe five systemic barriers to achieving extremely

high levels of safety in health care.

The landmark 2001 Institute of Medicine report Crossing

the Quality Chasm: A New Health System for the 21st Century

states the following:

Threats to patient safety are the end result of com-

plex causes such as faulty equipment; system design;

and the interplay of human factors, including

fatigue, limitations on memory, and distraction. The

way to improve safety is to learn about causes of

error and use this knowledge to design systems of

care so as to prevent error when possible, to make

visible those errors that do occur (so they can be

intercepted), and to mitigate the harm done when

an error does reach the patient.

10(p.78)

Toward that end, IHI promotes the following three-step

model for reducing errors and improving reliability in health

care systems:

1. Prevent failure (a breakdown in operations or functions).

Figure 1-1: A Mindful Infrastructure for High Reliability

Source: Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: Processes of collective mindfulness. Res Organizational Behav.

1999; 21(s 81):23–81. Used with permission.

2. Identify failure when it occurs and mitigate it (intercede)

before harm is caused or when failure is not detected.

3. Redesign the process based on the critical failures identified.

All three of these steps are integral to the concepts

described in this monograph and will be highlighted in

the case examples.

1.3 The Importance of a Safety

Culture

Chassin and Loeb describe the following three interdepen-

dent, essential changes that health care organizations must

undergo to become highly reliable

1. Leadership must commit to the goal of high

reliability.

Chapter 1: High Reliability in Health Care Organizations and Benefits to Improving Safety for Both Patients and Workers

Table 1-1: A State of Mindfulness for Nurses

Core Process Explanation/Implication for Nursing

Preoccupation with

failure

Adverse events are rare in HROs, yet these organizations focus incessantly on ways the system

can fail them. Rather than letting success breed complacency, they worry about success and know

that adverse events will indeed occur. They treat close calls as a sign of danger lurking in the sys-

tem. Hence, it is a good thing when nurses are preoccupied with the many ways that things can go

wrong and when they share that “inner voice of concern” with others.

Reluctance to simplify

interpretations

When things go wrong, less reliable organizations find convenient ways to circumscribe and limit the

scope of the problem. They simplify and do not spend much energy on investigating all the con-

tributing factors. Conversely, HROs resist simplified interpretations, do not accept conventional

explanations that are readily available, and seek out information that can disconfirm hunches and

popular stereotypes. Nurses who develop good interpersonal, teamwork, and critical-thinking skills

will enhance their organization’s ability to accept disruptive information that disconfirms precon-

ceived ideas.

Sensitivity to operations Workers in HROs do an excellent job of maintaining a big picture of current and projected opera-

tions. Jet fighter pilots call it situational awareness; surface Navy personnel call it maintaining the

bubble. By integrating information about operations and the actions of others into a coherent pic-

ture, they are able to stay ahead of the action and can respond appropriately to minor deviations

before they result in major threats to safety and quality. Nurses also demonstrate excellent sensitiv-

ity to operations when they process information regarding clinical procedures beyond their own jobs

and stay ahead of the action rather than trying to catch up to it.

Commitment to

resilience

Given that errors are always going to occur, HROs commit equal resources to being mindful about

errors that have already occurred and to correct them before they worsen. Here the idea is to

reduce or mitigate the adverse consequences of untoward events. Nursing already shows resilience

by putting supplies and recovery equipment in places that can be quickly accessed when patient

conditions go awry. Since foresight always lags hindsight, nursing resilience can be honed by creat-

ing simulations of care processes that start to unravel (e.g., failure to rescue).

Deference to expertise In managing the unexpected, HROs allow decisions to migrate to those with the expertise to make

them. Decisions that have to be made quickly are made by knowledgeable frontline personnel who

are closest to the problem. Less reliable organizations show misplaced deference to authority fig-

ures. While nurses, no doubt, can cite many examples of misplaced deference to physicians, there

are instances where physicians have assumed that nurses have the authority to make decisions

and act, resulting in a diffusion of responsibility. When it comes to decisions that need to be made

quickly, implicit assumptions need to be made explicit; rules of engagement need to be clearly

established; and deference must be given to those with the expertise, resources, and availability to

help the patient.

Abbreviation: HRO = High reliability organization

Source: Henriksen K, et al. Understanding adverse events: A human factors framework. In Hughes RG, editor: Patient Safety and Quality: An

Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US), 2008 Apr; Chapter 5. PubMed

PMID: 21328766.

2. An organizational culture that supports high reliability

must be fully implemented.

3. The tools of robust process improvement must be

adopted.

The second point, the importance of an organizational cul-

ture that supports high reliability, deserves special attention.

Briefly, in the last two decades there has been an explosion

of research on the impact of organizational culture in pre-

venting errors in both patient safety and worker safety.

12–17

Studies have looked for associations between culture and a

variety of staff outcomes such as turnover, satisfaction, and

injury rates, as well as patient outcomes such as satisfaction,

condition-specific functional status, infection rates, and

mortality rates.

Though terminology varies across fields, Stone et al.

and

Gershon et al.

provide concise descriptions of the differences

between the often-used terms organizational culture, climate,

and safety culture. Organizational culture refers to the deeply

embedded norms, values, beliefs, and assumptions shared by

members of an organization. These evolve over time and are

difficult to change. Climate, by contrast, refers to the shared

perceptions at a given point in time regarding organizational

practices such as decision making, advancement opportuni-

ties, and so on. These are more amenable to change. Safety

culture/safety climate is a subset (or microclimate) of overall

organizational climate that focuses on people’s perceptions

about the extent to which the organization values safety (for

workers, patients, and/or the environment), commits

resources to safety-related initiatives and equipment, and pro-

motes safe behaviors. Safety climate can serve as a leading

indicator of safety performance, in contrast to error and

injury rates, which are lagging indicators of performance.

As with all improvement activities, it is essential to measure

performance before and after trying to improve it. In fact,

hospitals and other organizations that are accredited by The

Joint Commission are expected to regularly evaluate the cul-

ture of safety and quality using valid and reliable tools.

Many valid and reliable safety and organizational culture

instruments are available to measure safety culture.

According to review articles by Gershon et al.,

Colla et al.,

and Sammer et al.

safety culture assessment tools addressing

worker or patient safety tend to focus on the dimensions

shown in Table 1-2. Though the practice of measuring safety

culture/climate is widespread, challenges remain regarding

construct validation and the appropriateness of using com-

parative information on safety culture.

22,23

Safety culture is known to vary widely across organizations,

and performance on the specific domains varies within

organizations. For example, it is conceivable that hospitals

may score high on dimensions related to patient safety but

low on worker safety. Similarly, studies have shown that per-

ception of culture varies between departments and units

within organizations (for example, ICUs may have a

stronger safety culture than medical/surgical floors) and by

type of respondent (physicians may have higher perceptions

of safety culture than nurses).

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Table 1-2: Common Dimensions Across Safety Culture Tools

Major Dimensions

Examples of Topic Areas:

Worker Safety Culture Tools

Examples of Topic Areas:

Patient Safety Culture Tools

Leadership and

management

Leadership and management support for staff

safety; degree of supervision, leadership hierar-

chy, policies and procedures

Perceptions of management; leadership and man-

agement support for patient safety; nonpunitive

response to errors, policies, and procedures; ade-

quacy of training

Group behaviors

and relationships

Workgroup relations, conflict vs. cooperation,

social relations, coworker trust, supportiveness

Teamwork within and across units; quality of hand-

offs and transitions

Communications Openness of communication, formal and informal

methods, conflict resolution approaches

Feedback and communication about error; report-

ing mechanisms

Quality of work life:

structural attributes;

working conditions

Staffing adequacy, job satisfaction, team satisfac-

tion, security; work pressure, rewards, job secu-

rity, forced overtime, benefits

Staffing adequacy, job satisfaction, team satisfac-

tion; resource availability; stress recognition

Measuring safety culture is actually the easier part; changing

and improving culture is much more challenging. Change

takes time—perhaps months or even years—and requires

specific interventions. Examples of a few interventions that

have been applied to improve safety culture are described in

Chapter 3 of this monograph. A recent Cochrane

Collaboration systematic review of the effectiveness of

strategies to change organizational culture to improve health

care performance identified more than 4,000 studies based

on their search criteria.

When the authors applied the

inclusion criteria of randomized clinical trials and/or well-

designed quasi-experimental studies, none of the studies was

eligible for inclusion. Thus, the authors were unable to draw

any conclusions about the effectiveness of different strategies

for improving organizational culture, and they identified a

major need for well-designed studies on this topic.

Finally, this chapter cannot begin to do justice to the wealth

of information available on safety culture. Readers are encour-

aged to visit the resources listed at the end of the chapter for

examples of safety culture tools and more information.

1.4 Why High Reliability Requires

Attention to Both Patient and Worker

Safety

HROs are deeply concerned with safety, and they value

near-miss events as opportunities to learn how to improve.

This preoccupation with safety must include both patient

and worker safety simultaneously, since staff working condi-

tions are related to patient safety as well as occupational

safety.

It would be expected, therefore, that HROs inte-

grate many patient and worker safety activities—either

structurally and/or functionally—within the organization.

A conceptual model (see Figure 1-2, page 12) developed by

Stone and a team of interdisciplinary scholars as part of the

Agency for Healthcare Research and Quality (AHRQ) research

portfolio, “The Effect of Health Care Working Conditions on

the Quality of Care” (RFA HS-01-005) shows the structural

and process factors that affect outcomes for both workers and

patients.

Some of the relationships are direct, while others are

indirect. For example, leaders have a direct effect on work

design and quality emphasis, which in turn indirectly affects

patient outcomes. Leaders also have a direct effect on worker

outcomes, such as satisfaction and intention to leave; workers

then have a direct effect on patient outcomes.

The evidence that worker satisfaction and characteristics of

the work environment affect patient outcomes continues to

grow. For example, McHugh et al. found that patient satis-

faction levels were lower in hospitals with more nurses who

are dissatisfied or burned out.

Taylor et al. found that

lower perception of safety and teamwork among nurses was

associated with increased odds of decubitus ulcers in

patients and increased nurse injury.

The study also found

that more nursing hours per patient day was associated with

fewer patient falls. A review by Stone et al. includes an evi-

dence table describing 16 earlier studies that examine the

relationship between organizational climate and patient and

worker outcomes.

Interestingly, the relationship between

worker outcomes and patient characteristics and outcomes is

bidirectional. McCaughey and colleagues reported that

health care workers who routinely care for high risk patients

(for example, patients who are cognitively impaired, mor-

bidly obese, or infected with contagious pathogens) were

more likely to have poorer perceptions of safety climate and

higher levels of stress.

However, organizational safety cli-

mate was found to mediate the relationship between high

risk patients and worker stress.

Given that poorer safety culture and working conditions are

associated with undesirable outcomes for workers, and

undesirable worker outcomes are associated with poorer

patient outcomes, it stands to reason that health care organi-

zations preoccupied with safety should not focus on patient

safety alone. HROs must recognize the inseparable integra-

tion of worker safety and patient safety and address worker

health and safety as well as patient safety.

1.5 Potential Benefits to Improving

Safety for Patients, Staff, and

Organizations and Return on

Investment (ROI) Considerations

There are a great many clinical and nonclinical areas, pro-

grams, and departments in which improvements can be

made that simultaneously benefit workers and patients.

Table 1-3, page 13, describes examples of the topics as well

as interventions and outcomes that can be improved for

patients, workers, and the health care organization as a

whole. The topics range from well-known areas such as falls,

safe patient handling, and violence prevention, to lesser-

known topics such as active surveillance for environmental

hazards and improving civility, respect, and teamwork.

Not all interventions require large investments of resources.

For example, implementing daily huddles that focus on

worker and patient safety hazards within or across units

minimizes staff time and optimizes real time identification

Chapter 1: High Reliability in Health Care Organizations and Benefits to Improving Safety for Both Patients and Workers

of actual or potential problems. See Chapter 3 for more

information.

Can one demonstrate an ROI for implementing these

improvements? Is it really cost effective to invest in capital

equipment or lengthy employee-driven process improve-

ment initiatives that divert precious resources from patient

care? Throughout this monograph, case studies highlight

real-life examples of benefits and ROIs that health care

organizations have experienced. Methods and approaches to

calculating ROI range from relatively simple for internal use

to sophisticated analyses suitable for peer-reviewed publica-

tions. See Resources 1-2, page 22, for further information.

Nevertheless, there currently is a dearth of literature on the

direct and indirect financial benefits of these efforts. In a

review of studies linking organizational climate to worker

and patient outcomes, Stone et al. found very few studies

that address the business case for improving worker and

patient safety and called for further research on specific

interventions and their cost effectiveness.

One community hospital that has proactively tackled the

intersection between worker and patient safety in its quest

for becoming an HRO is described in Case Study 1-1 that

follows on page 15.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Figure 1-2: An Integrative Model of Health Care Working Conditions on

Organizational Climate and Safety

Boxes outlined with dotted lines represent domains of organizational climate. Boxes outlined with solid lines represent out-

comes. Core domains are in bold; subconstructs are bulleted. The dotted arrows connecting core structural domains repre-

sent direct effects on outcomes, which are mediated by the process domains.

Source: Stone PW, et al. Organizational climate of staff working conditions and safety—An integrative model. In: Henriksen K, et al. editors.

Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville (MD): Agency for

Healthcare Research and Quality (US); 2005 Feb. PubMed PMID: 212498253.

Chapter 1: High Reliability in Health Care Organizations and Benefits to Improving Safety for Both Patients and Workers

Table 1-3: Topic Areas for Interventions to Improve Safety and

Examples of Potential Benefits to Patients, Staff, and Organizations

Intervention

Focus

Examples of

Strategies

Examples of

Settings

Potential Benefits

to Patients

Potential Benefits

to Employees

Potential Benefits

to the Health Care

Organization

Safe patient

handling

Patient lifting

equipment; no-lift

policies; special-

ized lift teams

Acute care hospi-

tals, rehabilitation

facilities, skilled

nursing facilities

Increased patient

satisfaction;

quicker ambula-

tion; fewer falls;

improved

outcomes

Increased worker

satisfaction;

decreased muscu-

loskeletal injuries

Decreased worker

compensation;

increased staff

retention;

increased patient

satisfaction,

returns, recom-

mendations

Fall prevention Patient assess-

ment; safe-transfer

technique; slip-

resistant flooring

materials;

absorbent floor

mats

All Decreased mor-

bidity and mortal-

ity, length of stay

Fewer injuries and

days away or

restricted work

Decreased worker

compensation

costs; decreased

litigation;

decreased staff

replacement

Sharps injury

prevention

Sharps with engi-

neered sharps

injury protections;

blunt suture nee-

dles to prevent

needle sticks, sur-

gical injuries; mini-

mize hand

transfers of surgi-

cal instruments

Acute and long

term care hospi-

tals, home health,

ambulatory

surgery

Decreased expo-

sure to blood-

borne pathogens

Decreased expo-

sure to blood-

borne pathogens

Decreased worker

compensation

claims, insurance

costs; decreased

litigation; improved

safety culture

Infection

prevention

Health care worker

immunization;

hand hygiene;

standard precau-

tions; personal

protective

equipment

All Decreased trans-

mission of organ-

isms from workers

to patients and

patients to patients

Decreased trans-

mission of organ-

isms from patients

to workers

Increased adher-

ence to guidelines;

fewer sick days;

lower externally

reported infection

rates; less risk of

financial penalties

in pay-for-perform-

ance initiatives

Assault and vio-

lence prevention

and management

Frontline staff and

security staff train-

ing; track patients

with history of dis-

ruptive behavior

All Fewer injuries and

adverse events;

less use of

restraints

Fewer injuries;

less anxiety;

improved team-

work; improved

satisfaction

Lower staff

turnover, litigation;

improved safety

culture

Security in the

neighborhood and

facility

Lights, locks,

video surveillance;

training on threat

recognition

Home health, hos-

pitals, nursing

homes

Patients less fear-

ful of violence in

parking areas,

facilities

Providers maintain

patient base;

greater sense of

security

Lower staff

turnover; improved

safety culture

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Table 1-3: Topic Areas for Interventions to Improve Safety and Examples of

Potential Benefits to Patients, Staff, and Organizations (continued)

Intervention

Focus

Examples of

Strategies

Examples of

Settings

Potential Benefits

to Patients

Potential Benefits

to Employees

Potential Benefits

to the Health Care

Organization

Prevent exposure

to hazardous

drugs

Ventilated cabi-

nets; closed-

system transfer

devices; needle-

less systems;

administrative con-

trols; proper per-

sonal protective

equipment

Acute care,

pharmacies,

oncology clinics

Lower risk of

exposure for

patients and their

families, workers,

and others

Lower risk of

adverse outcomes

such as infertility,

allergic reactions

Lower staff

turnover; less liti-

gation; improved

safety culture;

decreased workers

compensation

costs; improved

regulatory

compliance

Active surveil-

lance, analysis

and feedback of

adverse events,

environmental

hazards and risks

Reporting “near

misses”; safety

walk-arounds;

periodic health

and safety

inspections

All Fewer hazards

and adverse

events in patients

Fewer injuries and

illness; increased

satisfaction

Increased opportu-

nities to intervene

before harm

occurs; better

quality data;

improved compli-

ance with regula-

tory and oversight

bodies; improved

safety culture

Ergonomics and

human factors

engineering, work

flow redesign

Adaptive clothing

and scheduled

toileting for resi-

dents; mechanical

lift equipment;

supply kits; toilet

seat risers

All Quicker recovery;

increased satisfac-

tion; decreased

errors; quicker

staff response

Fewer errors;

increased effi-

ciency; fewer

injuries; increased

satisfaction

Higher reliability;

improved adher-

ence to guidelines;

improved effi-

ciency; decreased

turnover and

absenteeism, work-

related illnesses

Appropriate

staffing levels, mix

and workload

assignments

Work-hour restric-

tions, evidence-

based shift length,

rotation, rest

periods

All Lower mortality

(failure to rescue);

fewer fatigue-

related adverse

events; increased

patient satisfaction

Decreased stress

and burnout;

enhanced morale,

quality of work life

Decreased

turnover; decreased

absenteeism,

work-related ill-

nesses; improved

publicly-reported

patient satisfaction;

increased market

share; improved

safety culture

Improving safety

culture/climate and

teamwork

Engaging workers

and engaging

patients in safety

activities; leader-

ship rounds; daily

huddles

All Fewer adverse

events; increased

satisfaction

Enhanced morale,

employee satisfac-

tion; decreased

fatigue and

burnout

Improved patient

and worker out-

comes; decreased

litigation; improved

reputation;

decreased

turnover

St. Vincent’s Medical Center is one of 75 member hospitals

of Ascension Health, the largest Catholic not-for-profit

health care delivery system and the third-largest overall in

the United States. In 2002, Ascension Health (AH) initiated

a systemwide transformational change with a goal of provid-

ing excellent clinical care with a reduction in preventable

injuries or deaths by July 2008.* One hundred and twenty

AH leaders met and articulated a call to action to provide

“health care that works, health care that is safe, and health care

that leaves no one behind.” To translate this vision to action,

an agenda for change was created that defined strategies to

achieve goals, identified challenges to the agenda, and estab-

lished measurements of progress.

†

Examples of environmental challenges that needed to be

considered to successfully implement a transformational

change process include culture, infrastructure investments,

and standardization.

†

Two fundamental cultural issues—

namely, teamwork and patient safety—became central for

the system. Leadership at St. Vincent’s realized that the high

reliability platform implemented for patient safety would be

beneficial for employee harm reduction work, too.

Therefore, a single safety platform was adopted for all indi-

viduals in the health care organization, including patients

and health care workers (called “associates” at St. Vincent’s).

In addition, St. Vincent’s is one of three AH hospitals using

the approach to achieve OSHA Voluntary Protection

Program (VPP) status. This case study describes the experi-

ence of making safety for all—patients and associates—part

of the culture and transformation process at St. Vincent’s.

Applying the Patient Safety Platform to Associates

St. Vincent’s efforts toward developing a unified safety plat-

form began in 2008. The medical center’s efforts were

grounded in an organizational foundation that includes the

following concepts:

• Just culture

• Service line organization

• Committed leadership

• National system support

• OSHA VPP work

• Quality outcome successes

• Accountability model

• Engaged board of directors

Using the patient safety platform, associate safety events

were defined as follows:

• Serious Safety Event (SSE)—Reaches the associate and

results in lost time from work

• Precursor Safety Event—Reaches the associate, results in

minimal harm or no detectable harm with no lost time

• Near Miss Event—Does not reach the associate, error is

caught by detection barrier designed to prevent the event

Baseline data were gathered on the number of health care associ-

ate SSEs, days between events, and major causes (failure modes).

Chapter 1: High Reliability in Health Care Organizations and Benefits to Improving Safety for Both Patients and Workers

Table 1-3: Topic Areas for Interventions to Improve Safety and Examples of

Potential Benefits to Patients, Staff, and Organizations (continued)

Intervention

Focus

Examples of

Strategies

Examples of

Settings

Potential Benefits

to Patients

Potential Benefits

to Employees

Potential Benefits

to the Health Care

Organization

Safer design of

practices and built

environment

Improved ventila-

tion, surfaces,

water systems, pri-

vate rooms, room

design, and equip-

ment proximity;

healing environ-

ments

Facility-based

settings

Fewer health

care–associated

infections; quieter;

increased satisfac-

tion; faster healing

Decreased stress;

increased effi-

ciency; fewer

errors; improved

security

Increased satisfac-

tion; increased

staff retention;

increased patient

loyalty; improved

safety culture

CASE STUDY 1-1:

UILDING A HIGH RELIABILITY CULTURE

FOR

PATIENTS AND HEALTH CARE

WORKERS, ST. VINCENT’S MEDICAL

CENTER, BRIDGEPORT, CONNECTICUT

Building Will and Leadership Involvement

For a safety program to be successful, senior leadership sup-

port and active participation is deemed essential. To build

good will, a combination of approaches was used, including

senior leader-led education and storytelling. The storytelling

was particularly powerful, as the chief executive officer

(CEO) shared stories of inadvertent harm that had occurred

locally. Active support and involvement began with the

board of trustees, the CEO, and senior leadership. The

CEO was established as the executive sponsor. The director

of Occupational Health and the director of Safety and

Security became the operational leaders for the associate

safety work, and the director of Quality and Patient Safety

was named the operational leader for the patient safety

work. Staff champions were identified and all staff, includ-

ing physicians, were involved. The engagement of senior

leadership and frontline managers was crucial in gaining

staff buy-in and was a critical factor in the program’s initial

success.

Steps to Creating a Culture of Patient and

Associate Safety

When leadership commitment was obtained, a structured

process was instituted to build organizationwide awareness

and support for the change process. A toolbox of high relia-

bility behaviors based on findings from a comprehensive

organizational assessment was created with the input of

frontline staff. Roll-out of the toolbox was accomplished

through education; all associates completed 3.5 hours of

mandatory training conducted by senior leaders, inclusive of

the CEO along with a key middle manager. Medical staff

education commenced with a two-day retreat that focused

on high reliability and safety and included actual physician-

centric case studies of harm-related error. Approximately a

dozen private physicians volunteered and were trained to

conduct education for the remaining private medical staff.

The Medical Executive Committee voted to make the high

reliability safety training mandatory for eligibility for reap-

pointment. To support actualization of high reliability

behaviors, a host of operational infrastructures were imple-

mented, such as daily in-house huddles (see Case Study

Figure 1-1), unit-based huddles, meetings starting with a

topic of safety (including the board meeting), senior leader

rounding, safety coaches, robust root cause analysis for harm

events, performance metrics that are reported via the

intranet, a dashboard, and transparency in sharing stories of

safety events. See Case Study Table 1-1, page 17, for

descriptions of many of these activities.

Making patient and associate safety a part of the culture at

St. Vincent’s was facilitated by a comprehensive organiza-

tional approach that addresses policies and procedures;

resource allocation (staffing, equipment, capital expendi-

tures); organizational structures (committees, departments,

lines of authority); risk and hazard assessment; adverse-event

surveillance systems and analysis; and performance measure

data collection, analysis, and use. Error prevention is opti-

mized by matching safety behaviors with error prevention

tools to support individual action and promote teamwork

(see Case Study Figure 1-2, page 17). Important among

these behaviors is rewarding successes with immediate recog-

nition. As noted previously, feedback on performance met-

rics is also made available organizationwide on the intranet.

Posters displaying measurement outcomes, such as the num-

ber of days without an accident, provide visual reminders of

success. While high reliability behaviors were more quickly

adopted for patients, a persistent focus and relentless pursuit

of eliminating associate harm has become standard to core

safety work.

Measuring Improvement and Realizing Benefits

Multiple metrics provide quantitative evidence of improved

safety outcomes. A primary patient quality improvement

metric identified in the clinical transformation at AH is the

elimination of preventable injuries and deaths. Performance

measurement data documents a systemwide reduction in

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Case Study Figure 1-1: Daily

Huddle (St. Vincent’s)

Source: St. Vincent’s Medical Center. Bridgeport, CT. Used with

permission.

Chapter 1: High Reliability in Health Care Organizations and Benefits to Improving Safety for Both Patients and Workers

preventable deaths in fiscal year 2010

that exceeds targeted goals.* Across AH

hospitals, rates on other priorities

(National Patient Safety Goals) are con-

sistently better than national averages.

For example, in fiscal year 2010 the AH

system rate for pressure ulcers was 0.86

per 1,000 inpatient days—94% lower

than the estimated national incidence of

15.44.* Performance metrics used at

St. Vincent’s to track improvement in

associate health and safety include OSHA

reportable events, the DART (days away,

restricted, or transferred) rate, SSE rate,

days between events, and days between

needlestick injuries. Performance data

shows a significant decline in all rates

except needlestick injuries.

The most important return on invest-

ment has been in the reduction of harm

for patients and associates. In addition,

high reliability work in patient care at

Case Study Table 1-1: Infrastructure Activities to Support

High Reliability Behaviors, St. Vincent’s Medical Center

Activity Description

Daily housewide huddles Daily briefings led by senior leadership to review safety events and concerns across the

whole organization. Participation is nonnegotiable.

Unit-based huddles Briefings to review safety events and concerns raised at the unit level. May be brought

to housewide huddle by unit leadership as necessary.

Senior leader rounding Leaders working in pairs adopt specific departments to round for patient and associate

safety issues. Interactions build relationships and trust.

Safety coaches Staff-level associates who applied and were accepted to be frontline coaches for high

reliability safety work. These highly visible local-level champions monitor, train, coach

and hold regular meetings to promote patient and associate safety.

Root cause analysis for harm

events

A highly structured approach for conducting root cause analysis (for both patient and

associate harm events), which facilitates stratification of contributing factors. Starts with

focus on serious safety events and expands to precursor events and near misses as

harm events decrease.

Performance metrics and

dashboard

High-level metrics include SSE rate and days between harm events (both patient and

associate). Detailed dashboards stratify results by unit, discipline, error type, etc.

Storytelling of safety events The use of real-life examples to personalize important issues and events.

Source: St. Vincent’s Medical Center. Bridgeport, CT. Used with permission.

Case Study Figure 1-2: Safety Is the Key to

T.R.U.S.T., Error Prevention Techniques,

St. Vincent’s Medical Center

Source: St. Vincent’s Medical Center. Bridgeport, CT. Used with permission.

AH has led to reduced malpractice costs. As sufficient asso-

ciate health and safety performance outcome data over time

becomes available, savings based on costs for workers’ com-

pensation, nonproductive time on the job, sick time, and so

on will be calculated.

Shared Lessons

Making safety an organizationwide priority for patients and

associates can be achieved when it is part of the culture and

core values. A focus on error prevention and preoccupation

with safety will maximize improved outcomes for everyone

in the health care setting. Success demands that there can be

no bystanders in this work; everyone must be an active par-

ticipant. Safety at St. Vincent’s is not viewed as a “program”

but rather the core foundation of their work—a job that

will never be completed.

Case Study References

* Pryor D, et al. The quality ‘journey’ at Ascension Health: How

we’ve prevented at least 1,500 avoidable deaths a year—and aim

to do even better. Health Aff (Millwood). 2011

Apr;30(4):604–611. PubMed PMID: 21471479.

† Pryor DB, et al. The clinical transformation of Ascension Health:

Eliminating all preventable injuries and deaths. Jt Comm J Qual

Patient Saf. 2006 Jun;32(6):299–308. PubMed PMID: 16776384.

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3 Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high relia-

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America [Internet]. Washington (DC): National Academy Press;

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Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Case Study Sidebar 1-1:

Summary of Success Factors

The following factors helped make St. Vincent’s program

a success.

1. Highly visible CEO and executive staff living safety as

a core value

2. Physician champions demonstrating and teaching

error prevention techniques and modeling teamwork

3. Frontline staff integrated into the team through reward

and information

4. Lifetime learning mindset

5. Storytelling and transparency

6. Just culture

7. Accountability infrastructure

8. Relentless focus

Source: St. Vincent’s Medical Center. Bridgeport, CT. Used with

permission.

Rockville (MD): Agency for Healthcare Research and Quality

(US); 2008 Apr. Chapter 21. PubMed PMID: 21328736.

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18 Gershon RM, et al. Measurement of organizational culture and

climate in healthcare. J Nurs Adm. 2004 Jan:34(2):33–40.

19 The Joint Commission. 2012 Comprehensive Accreditation

Manual for Hospitals: Leadership Standard LD.03.01.01. Oak

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20 Colla JB, et al. Measuring patient safety climate: A review of sur-

veys. Qual Saf Health Care. 2005;14(5):364–366.

21 Sammer CE, et al. What is patient safety culture? A review of the

literature. J Nurs Scholarsh. 2010 Jun; 42(2):156–165. Review.

PubMed PMID: 20618600.

22 Burns C, Mearns K, McGeorge P. Explicit and implicit trust

within safety culture. Risk Anal. 2006;26(5):1139–1150.

23 Ginsburg L, et al. Advancing Measurement of Patient Safety

Culture. Health Serv Res. 2009;44(1):205–224.

24 Singer SJ, et al. Patient safety climate in 92 hospitals differences

by work area and discipline. Med Care. 2009;47(1):23–31.

25 Parmelli E, et al. The effectiveness of strategies to change organisa-

tional culture to improve healthcare performance. Cochrane

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26 Hickam DH, et al. The effect of health care working conditions

on patient safety. Evid Rep Technol Assess (Summ). 2003

Mar;(74):1–3. PubMed PMID: 12723164.

27 Stone PW, et al. Organizational climate of staff working condi-

tions and safety—an integrative model. In: Henriksen K, et al.

editors. Advances in Patient Safety: From Research to

Implementation (Volume 2: Concepts and Methodology).

Rockville (MD): Agency for Healthcare Research and Quality

(US); 2005 Feb. PubMed PMID: 212498253.

28 McHugh MD, et al. Nurses’ widespread job dissatisfaction,

burnout, and frustration with health benefits signal problems for

patient care. Health Aff (Millwood). 2011 Feb;30(2):202–210.

PubMed PMID: 21289340; PubMed Central PMCID:

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29 Taylor JA, et al. Do nurse and patient injuries share common

antecedents? An analysis of associations with safety climate and

working conditions. BMJ Qual Saf. 2012 Feb;21(2):101–111.

Epub 2011 Oct 19. PubMed PMID: 22016377.

30 McCaughey D, et al. Perception is reality: How patients con-

tribute to poor workplace safety perceptions. Health Care Manage

Rev. 2011;36(1):18–27.

Chapter 1: High Reliability in Health Care Organizations and Benefits to Improving Safety for Both Patients and Workers

Resources 1-1: Examples of Safety Culture Surveys

Instrument Title Source and Location Type / Domains / Dimensions / Subcontracts

Hospital Survey on Patient Safety Culture (HSOPS)

http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm

Two other surveys on patient safety culture are available from AHRQ

as well:

• Medical Office Survey on Patient Safety Culture

http://www.ahrq.gov/qual/patientsafetyculture/mosurvindex.htm

• Nursing Home Survey on Patient Safety Culture

http://www.ahrq.gov/qual/patientsafetyculture/nhsurvindex.htm

Agency for Healthcare Research and Quality (AHRQ) [Internet].

Rockville (MD): Agency for Healthcare Research and Quality; 2011 Mar

[updated 2012 Jan; cited 2011 Aug 11]. Hospital Survey on Patient

Safety Culture; [about 3 screens]. Available from:

http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm.

Sorra JS, Nieva VF. Rockville (MD): Agency for Healthcare Research

and Quality; [updated 2004 Sep; cited 2011 Aug 11]. Hospital Survey on

Patient Safety Culture, AHRQ Publication No. 04-0041 [about 74 p.].

Available from: http://www.ahrq.gov/qual/patientsafetyculture/usergd.htm.

Assesses patient safety culture. Domains include

supervisor/manager expectations and actions pro-

moting patient safety; organizational learning—con-

tinuous improvement; teamwork within hospital

units; communication openness; hospital manage-

ment support for patient safety; feedback and com-

munication about error; nonpunitive response to

error; staffing

AHRQ toolkit of related products includes survey

user’s guide, feedback report template, and com-

parative database for optional submission

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Resources 1-1: Examples of Safety Culture Surveys (continued)

Instrument Title Source and Location Type / Domains / Dimensions / Subcontracts

Safety Attitudes Questionnaire

Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, et

al. The Safety Attitudes Questionnaire: psychometric properties, bench-

marking data, and emerging research. BMC Health Serv Res. 2006 Apr

3;6:44. PubMed PMID: 16584553; PubMed Central PMCID:

PMC1481614.

Sexton JB, Thomas EJ, Helmreich RL, et al. Frontline assessments of

health care culture: Safety Attitudes Questionnaire norms and psycho-

metric properties. Austin, TX: The University of Texas Center of

Excellence for Patient Safety Research and Practice, 2004. Technical

Report No. 04-01. Grant No. 1PO1HS1154401. Sponsored by the

Agency for Healthcare Research and Quality.

Sexton JB, Thomas EJ. The Safety Climate Survey: psychometric and

benchmarking properties. Austin, TX: The University of Texas Center of

Excellence for Patient Safety Research and Practice, 2003. Technical

Report 03-03. Grant Nos 1PO1HS1154401 and U18HS116401.

Sponsored by the Agency for Healthcare Research and Quality.

Assesses patient safety culture. Measures six fac-

tors: teamwork climate, safety climate, perceptions

of management, job satisfaction, working condi-

tions, and stress recognition

Patient Safety Culture in Healthcare Organizations Survey (PSCHO)

Singer S, Meterko M, Baker L, Gaba D, Falwell A, Rosen A. Workforce

perceptions of hospital safety culture: Development and validation of

the patient safety climate in health care organizations survey. Health

Serv Res. 2007 Oct;42(5):1999–2021. PubMed PMID: 17850530;

PubMed Central PMCID: PMC2254575.

Assesses nine constructs: senior management

engagement; organizational resources; overall

emphasis on safety; unit safety norms; unit recogni-

tion and support for safety; fear of shame; fear of

blame; collective learning, provision of safe care

Modified Stanford Instrument (MSI) Patient Safety Culture Survey

Ginsburg L, Gilin D, Tregunno D, Norton PG, Flemons W, Fleming M.

Advancing measurement of patient safety culture. Health Serv Res.

2009 Feb;44(1):205–224. Epub 2008 Sep 17. Erratum in: Health Serv

Res. 2009 Feb;44(1):321. PubMed PMID: 18823446; PubMed Central

PMCID: PMC2669635.

Tool for measurement of organizational safety cul-

ture or climate

Modified Organizational Climate Description Questionnaire (OCDQ)

Halpin AW, Croft DB. The Organizational Climate of Schools.

International Review of Education Internationale Zeitschrift fur

Erziehungswissenschaft Revue Internationale de pedagogie

22.4(1963): 441–463. Print.

Likert-type instrument assessing group and leader

behaviors (four group and four leader), and deter-

mining organizational climate along six climate

types arranged along a continuum of open to closed

Organizational Climate Questionnaire

Litwin GH, Stringer RA. Motivation and Organizational Climate. Division

of Research, Graduate School of Business Administration, Harvard

University, 1968. Print.

Composed of nine climate dimensions: structure,

responsibility, reward, risk, warmth, support, stan-

dards, conflict, and identity

Chapter 1: High Reliability in Health Care Organizations and Benefits to Improving Safety for Both Patients and Workers

Resources 1-1: Examples of Safety Culture Surveys (continued)

Instrument Title Source and Location Type / Domains / Dimensions / Subcontracts

The Practice Environment Scale of the Nursing Work Index (PES-NWI)

National Quality Forum (NQF) Endorsed Nursing-Sensitive Care

Performance Measures. Available at: http://www.jointcommission.org

/assets/1/6/NSC%20Manual.pdf or http://www.jointcommission.org

/library_of_other_measures.aspx.

A survey measure of the nursing practice environ-

ment completed by staff registered nurses; includes

mean scores on index subscales and a composite

mean of all subscale scores

Safety and Health Leadership Quiz

U.S Department of Labor, Occupational Safety and Health

Administration [Internet]. Washington (DC); [cited 2011 Aug 11].

Safety and Health Leadership Quiz; [about 2 screens]. Available from:

http://www.osha.gov/SLTC/etools/safetyhealth/comp1_mgt_lead

_leadershipquiz.html.

Part of a larger module that includes tools on safety

and health payoffs, management systems (safety

and health integration), conducting a safety and

health checkup, and creating change

Strategies for Leadership: An Organizational Approach to Patient Safety

(SLOAPS)

Voluntary Hospitals of America. Strategies for Leadership: An

Organizational Approach to Patient Safety, 2000.

Assesses five common dimensions: leadership,

policies and procedures, staffing, communication,

and reporting. Also addresses other dimensions of

patient safety climate.

Institute for Safe Medication Practices (ISMP):

Medication Safety Self Assessment (MSSA)

Medication Safety Self Assessment for Hospitals, 2011. Available from

http://www.ismp.org/survey.

For hospital setting—assesses leadership, policies

and procedures, staffing, communication, reporting,

and other dimensions.

Hospital Transfusion Service Safety Culture Survey (HTSSCS)

Sorra J, Nieva VF. Psychometric analysis of MERS-TM Hospital

Transfusion Service Safety Culture Survey. Westat, under contract to

Barents/KPMG, 2002. Contract No. 290-96-0004. Sponsored by the

Agency for Healthcare Research and Quality.

Assesses communication, reporting, (and to an

extent) leadership, and policies and procedures

Veterans Administration Patient Safety Culture Questionnaire (VHA PSCQ)

Burr M, Sorra J, Nieva VF. Analysis of the Veterans Administration (VA)

National Center for Patient Safety (NCPS) FY 2000 Patient Safety

Questionnaire. Technical report. Rockville (MD): Westat; 2002. Contract

No. 290-96-0004. Sponsored by the Agency for Healthcare Research

and Quality.

Assesses leadership, policies and procedures,

staffing, communication, and reporting

Culture of Safety Survey (CSS)

Weingart SN, et al. Using a multihospital survey to examine the safety

culture. Jt Comm J Qual Saf. 2004;30:125–132.

Measures the presence of leadership, salience,

nonpunitive environment, reporting, and communi-

cation

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Resources 1-2: Resources Related to Models for Demonstrating Value

Title and Website Description

Agency for Healthcare Research and Quality (AHRQ)

Tool

Return on Investment Estimation

http://www.ahrq.gov/qual/qitoolkit/f1_returnoninvestment.pdf

Provides a step-by-step method for calculating the

ROI for a new set of actions implemented to

improve performance on one or more of the AHRQ

Quality Indicators (QIs)

Audio Teleconference

Can You Minimize Health Care Costs by Improving Patient Safety?

http://archive.ahrq.gov/news/ulp/costsafetele/

Web-assisted audio teleconference consists of

three sessions broadcast via the World Wide Web

and telephone September 20, 30, and October 1,

2002. The program explored the business case for

patient safety, how to overcome barriers, and practi-

cal solutions to help states and health care facilities

improve patient safety. The User Liaison Program of

the AHRQ developed and sponsored the program.

Center for Health Care Strategies

Web-Based Tool

ROI Forecasting Calculator for Quality Initiatives

http://www.chcsroi.org/Welcome.aspx

Web-based tool designed to help state Medicaid

agencies, health plans, and other stakeholders

assess and demonstrate the cost-savings potential

of efforts to improve quality. It provides step-by-step

instructions for users to calculate ROI for the pro-

posed quality initiatives.

Centers for Disease Control and Prevention (CDC)

Tutorial

Cost-Effectiveness Analysis (CEA)

http://www.cdc.gov/owcd/EET/costeffect2/fixed/1.html

Provides information about the use of CEA, a type

of economic evaluation that examines both the

costs and health outcomes of alternative interven-

tion strategies

Institute for Healthcare Improvement (IHI)

Tool

Adverse Events Prevented Calculator

http://www.ihi.org/knowledge/Pages/Tools/AdverseEventsPrevented

Calculator.aspx

Users track the change in rate of any type of adverse

event over time. When appropriate data are added,

the user can also track the consequent change in

unnecessary deaths (“lives saved”), real and addi-

tional potential cost savings, and ROI of quality

improvement work targeting those adverse events.

National Institute for Occupational Safety and Health (NIOSH)

Report

Examining the Value of Integrating Occupational Health and Safety and

Health Promotion Programs in the Workplace

http://www.factsforhealthcare.com/management/Assets/NIOSH

_Background_Paper_Goetzel.pdf

Examines the role of worker health as a key con-

tributing factor to increases in workplace productiv-

ity and the emergence of organizational practices

that support the integration of occupational health,

safety, and productivity management programs

Blogpost

Getting Closer to Understanding the Economic Burden of Occupational

Injury and Illness

http://blogs.cdc.gov/niosh-science-blog/2012/03/oshcost/

Comments on a recently published landmark paper

by J. Paul Leigh (Milbank Q. 2011;89(6):728–772)

that makes a significant contribution to understand-

ing the economic burden of occupational illness and

injury

Chapter 1: High Reliability in Health Care Organizations and Benefits to Improving Safety for Both Patients and Workers

Resources 1-2: Resources Related to Models for Demonstrating Value (continued)

Title and Website Description

National Institute for Occupational Safety and Health (NIOSH) [continued]

Report

Pana-Cryan R, Caruso CC, and Boiano JM.

Chapter 10: The Business Case for Managing Worker Safety and

Health.

In: US Department of Health and Human Services, Centers for Disease

Control and Prevention, National Institute for Occupational Safety and

Health [Internet]. State of the Sector | Healthcare and Social

Assistance: Identification of Research Opportunities for the Next

Decade of NORA. DHHS (NIOSH) Publication Number 2009-139.

Available from: http://www.cdc.gov/niosh/docs/2009-139

Discusses the current evidence and methodological

challenges associated with demonstrating ROI in

worker health and safety systems. It also presents

several case studies on a variety of topics.

Publications

Article

Weeks WB, Bagian JP. Making the business case for patient safety. Jt

Comm J Qual Saf. 2003 Jan;29(1):51–4, 1.

http://www.ncbi.nlm.nih.gov/pubmed/12528574

Explains why there appears to be a business case

for health care organizations to make investments

to enhance patient safety

Article

Hwang RW, Herndon JH. The business case for patient safety. Clin

Orthop Relat Res. 2007 Apr;457:21–34.

http://www.ncbi.nlm.nih.gov/pubmed/17259896

States that the business case for patient safety is a

compelling one, offering substantial economic

incentives for achieving the necessary goal of

improved patient outcomes

Occupational Safety and Health Administration (OSHA)

Publication

Safety and Health Add Value…

http://www.osha.gov/Publications/safety-health-addvalue.pdf

Informational material about how OSHA can assist

companies in creating better workplaces by provid-

ing assessments and helping to implement safety

and health management systems

Program

OSHA’s “$afety Pays” program

http://www.osha.gov/dcsp/smallbusiness/safetypays/index.html

An interactive expert system to assist employers in

estimating the costs of occupational injuries and ill-

nesses and the impact on a company’s profitability.

This system uses a company’s profit margin, the

AVERAGE costs of an injury or illness, and an indi-

rect cost multiplier to project the amount of sales a

company would need to generate in order to cover

those costs. Businesses can use this information to

predict the direct and indirect impact of injuries and

illnesses and the estimated sales needed to com-

pensate for these losses.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Resources 1-2: Resources Related to Models for Demonstrating Value (continued)

Title and Website Description

Occupational Safety and Health Administration (OSHA) [continued]

Web Links

Four case study examples from health care demonstrating the business

case for worker safety and health

http://www.osha.gov/dcsp/products/topics/businesscase/industry.html

• “Blue Cross Blue Shield Rhode Island.” OSHA

and Abbott Case Study (2005, February).

Communicates the business value and competi-

tive advantages of an effective safety and health

program

• “Countryside Care Nursing Home.” OSHA and

Abbott Case Study (2005, February).

Communicates the business value and competi-

tive advantages of an effective safety and health

program

• The Business Case for Occupational Health

Nurses [475 KB PDF, 4 pages]. American

Association of Occupational Health Nurses

(2007, May). Case studies and success stories

highlighting the business benefits of hiring or

partnering with occupational and environmental

health nurses

• Safe Lifting and Movement of Nursing Home

Residents. US Department of Health and Human

Services (DHHS), National Institute for

Occupational Safety and Health (NIOSH)

Publication No. 2006-1117 (2006, February).

Presents a business case to show that the

investment in lifting equipment and training for

moving nursing home residents can be recovered

through reduced workers’ compensation

expenses and reduced costs associated with lost

and restricted work days

Management Principles,

Strategies, and Tools

That Advance Patient and

Worker Safety and

Contribute to High Reliability

“

High reliability organizations are not immune to adverse events, but they have

learnt the knack of converting these occasional setbacks into enhanced resilience

of the system.”—James Reason

1(p.770)

Providing a safety culture and ensuring leadership involvement are increasingly recognized as essential aspects of

improving the quality and safety of care for patients.

2,3

They have long been identified as key factors in establishing

high reliability workplaces that strive to eliminate mistakes and prevent worker accidents.

4,5

Health care is now considered to be a high hazard and high risk industry for both patients and workers. Examples

of hazards for patients include sentinel events such as wrong-site surgeries and surgical complications, diagnostic

errors, restraint injuries, serious medication errors, transfusion errors, and healthcare–associated infections (HAIs).

6,7

Examples of potential hazards for workers include exposures to infectious, chemical, and physical (nuclear, electro-

magnetic energy, noise) agents; heavy lifting and repetitive tasks; slips, trips, and falls; stress; workplace violence;

and risks associated with suboptimal organization of work. These can lead to infections such as hepatitis, cancer

and poor reproductive outcomes, hearing loss, musculoskeletal injuries, cardiovascular disease, acute traumatic

injury, and death.

As documented in a recent National Occupational Research Agenda (NORA) report on the health care sector,

there were 668,000 episodes of nonfatal occupational illness and injury in 2005, which is equivalent to one episode

– Chapter 2 –

occurring every 47 seconds of that year. Compared to other

industrial sectors, the health care sector had the second-

largest number of such injuries and illnesses.

Although

worker illnesses and injuries in most work environments are

decreasing, the Occupational Safety and Health

Administration (OSHA) recently reported that the rate of

nonfatal injury and illness requiring days away from work

increased among some health care workers in 2010, accord-

ing to the US Department of Labor’s Bureau of Labor

Statistics. The incidence rate of nonfatal occupational

injuries and illnesses requiring days away from work for

health care support workers increased 6% to 283 cases per

10,000 full-time workers, almost 2

⁄2 times the rate for all

private and public sector workers (at 118 cases per 10,000

full-time workers). The rate among nursing aides, orderlies,

and attendants rose 7%, to 489 cases per 10,000 workers.

Additionally, the rate of musculoskeletal disorder cases with

days away from work for nursing aides, orderlies, and atten-

dants increased 10% to a rate of 249 cases per 10,000 work-

ers, more than seven times the rate for all private and public

sector workers (at 34 cases per 10,000 full-time workers).

High-hazard, high-risk industries demand attention to safety

in order to succeed. Greater awareness of worker safety and

health issues coincided with the growth of organized labor

in the early twentieth century. During the 1980s and 1990s,

published studies drew attention to worker safety issues

within the health care industry; however, many occupational

risks had been known for centuries.

By contrast, the

patient safety movement developed in the late 1990s and

was exponentially accelerated by publication of the land-

mark Institute of Medicine (IOM) report “To Err Is

Human: Building a Safer Health System” in 2000.

Despite

commonalities, the patient safety movement developed sepa-

rately from the worker safety movement and typically

involved different health care staff. In large health care

organizations, responsibility for health care worker safety

traditionally fell to staff in occupational safety and health,

employee health, infection prevention, and environmental

services. In small organizations, a single staff person often

performed many of these functions. Responsibility for

patient safety, on the other hand, typically was the domain

of the quality management or performance improvement

staff, often engaging medical staff leadership and risk man-

agement. This separation of patient and worker safety can

result in “departmental silos” of staff competing for leader-

ship attention and resources as well as fragmentation, dupli-

cation of effort, inefficiencies, and additional expense (see

Figure 2-1, below).

High reliability organizations, however, have likely learned

how to integrate or coordinate functions across departments

and to identify and maximize synergies where possible while

recognizing responsibilities that are unique to a specific pur-

pose and stakeholders.

In this chapter, we introduce a few management and

improvement concepts, principles, strategies, and tools that

facilitate identification of opportunities to integrate and col-

laborate across departments toward the goal of improved

safety for both patients and workers.

2.1 Safety Management

Systems: Common Elements

for Workers and Patients

In 1989 OSHA published voluntary safety

management system guidelines to help organi-

zations understand the structure and content

for excellence in occupational safety and health

programs.

The elements of these programs

comprise a management “system” because it is

“an established arrangement of components

that work together to attain a certain objective,

in this case to prevent injuries and illnesses in

the workplace. Within a system, all parts are

interconnected and affect each other”

(see

Figure 2-2, page 27). Key activities associated

with the elements are described in Table 2-1,

page 28.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Figure 2-1: Example of Past Hospital

Safety Committee Structures

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

Patient safety programs and management systems closely

parallel these activities. Table 2-2, page 30, presents the

analogous elements for patient safety as categories (rows),

then describes examples from the 2010 National Quality

Forum Safe Practices for Better Healthcare as well as exam-

ples of Joint Commission standards and elements of per-

formance that pertain to the categories.

Tables 2-1 and 2-2 highlight the common activities associ-

ated with improving safety for patients and workers in the

areas of leadership responsibility, training, hazard identifica-

tion, incident analysis, and improving safety culture. For

more information, see the sources for the table content and

other documents listed in Resources 2-1, page 41.

2.1.1 Civility in the Workplace

Closely associated with, and perhaps a necessary precursor

to, improving safety culture is the need to establish a civil

workplace in which staff treat each other and patients

with respect. Case Study 2-1 presents an example of a

broad scale effort within the Veterans Health

Administration (VHA) to improve civility in the work

environment.

Civility, Respect, and Engagement in the Workplace (CREW)

is a nationwide initiative developed by the VHA’s National

Center for Organization Development (NCOD) with a pri-

mary goal of changing organizational culture toward increasing

civility in the workplace.* CREW was first introduced in 2005

in response to All Employee Survey results and personal inter-

views indicating less-than-desirable levels of civility across the

organization. Top leadership endorsement for the development

of the CREW initiative was obtained based on the survey data

results and presentation of a business case that highlighted the

impact of workplace civility on costs (for example, sick leave),

safety issues, productivity, performance, and employee and

patient satisfaction. Health care workers are known to experi-

ence high levels of injury and stress, and are at risk for hori-

zontal violence and burnout (see Chapter 3, Section 3.4.1.1,

page 95). In addition to the personal costs to the employee,

staff burnout has serious negative effects on patient care and

satisfaction.

†

The National Leadership Board of the VHA has

endorsed civility as a core characteristic of an ideal workplace.

Defining CREW

CREW was developed at VHA’s NCOD as a short-term,

intensive intervention that is customized to each site and

workgroup, allowing them to define culturally specific civil

behaviors and select areas of focus for their particular setting.

For example, a rural hospital in a small midwestern commu-

nity and a large medical center in New York City may define

civility differently.* Common aspects across all sites include

standard training of local site leaders, educational toolkits, and

use of a civility scale to survey workgroup members before and

after the CREW intervention. Local site leaders facilitate hon-

est conversations and participation within the workgroup. In

addition to the use of training, practice, and toolkits, the

process is enhanced through weekly support calls with a “com-

panion” at NCOD. In addition, there are opportunities to

exchange experiences between CREW facilities. Based on

results of the pre-intervention survey, each workgroup typically

selects focus areas, and members are encouraged to design,

redesign, and test their interventions. Through their engage-

ment, employees provide and receive feedback on the success

or failure of various interventions. The civility survey is then

Figure 2-2: Four Interconnected

Components of a Safety and

Health Management System for

Workers

Source: Occupational Safety and Health Administration

[Internet]. [cited 2012 Jan 31]. US Department of Labor; [about

1 screen]. Overview of System Components. Available from:

http://www.osha.gov/SLTC/etools/safetyhealth/components.html.

CASE STUDY 2-1:

US D

EPARTMENT OF VETERANS AFFAIRS:

UILDING A CULTURE OF CIVILITY IN THE

WORKPLACE—CIVILITY, RESPECT, AND

ENGAGEMENT IN THE WORKPLACE

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Table 2-1: Key Elements and Activities Associated with OSHA Components

of Worker Safety and Health Management Systems

Elements of a

Worker Safety

and Health

Management

System

Activities

Leadership of

the system by

management

• Establish a safety and health policy

• Establish goals and objectives

• Provide visible top management leadership and involvement

• Ensure employee involvement

• Ensure assignment of responsibility

• Provide adequate authority and responsibility

• Ensure accountability for management, supervisors, and rank-and-file employees

• Provide a program evaluation

• Perform a thorough evaluation of contractors’ safety record to assure they do not become a safety liability

to a site. An OSHA citation history should be performed during all contract evaluations with specific safety

expectations built into the contract

Employee

involvement

• Participate on joint labor-management committees and other advisory groups

• Conduct site inspections

• Analyze routine hazards in each step of a job or process, and prepare safe work practices

• Participate in developing and revising safety rules

• Participate as trainers for current and new hires

• Participate in accident/near miss incident investigations

• Participate in decision making throughout the company’s operations

• Participate in pre-use and change analysis

• Participate as safety observers and safety coaches

• Report hazards and be involved in finding solutions to correct the problems

Analysis of

worksite

hazards

• Periodic, comprehensive safety, industrial hygiene, and health surveys

• Analysis of accident records, near miss reporting, and employee reporting of hazards or at-risk behaviors

• Routine hazard analysis, such as job hazard analysis, process hazard analysis, or phase hazard analysis

• Pre-use and change analysis of the potential hazards in new or startup of facilities, equipment, materials,

and processes

Prevention

and control of

workplace

hazards

Implement the Hierarchy of Controls

• Engineering controls: To the extent feasible, the work environment and the job itself should be designed to

eliminate or reduce exposure to hazards based on the following principles: (1) if feasible, design the facility,

equipment, or process to remove the hazard and/or substitute with something that is not hazardous or is

less hazardous; (2) if removal is not feasible, enclose the hazard to prevent exposure in normal operations;

and (3) where complete enclosure is not feasible, establish barriers to reduce exposure to the hazard

– Enclosure of hazards

– Barriers or local exhaust ventilation

• Elimination of hazards through design

• Administrative controls

• PPE

Safety and

health training

• Identify training needs

• Safety training at orientation

• Periodic training

• Evaluate training effectiveness

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

repeated after the intervention to measure change. CREW was

initially piloted at eight sites in 2005, and has now expanded

to include more than 1,000 workgroups, encompassing all

clinical and administrative disciplines.

Measuring Improvement and Workplace Impact

In a study to conduct a preliminary evaluation of CREW,

Osatuke et al.* found that sites that had implemented

CREW showed significant improvement in post-interven-

tion civility ratings, as opposed to comparison sites that did

not. Specifically, data collected for more than five years has

demonstrated that higher civility is associated with fewer

sick leave hours and fewer equal employment opportunity

(EEO) complaints. CREW has also been found to be an

effective tool in addressing horizontal violence and

employee/supervisor conflict as well as positively affecting

the quality of interactions with patients and families. Some

cost savings have been approximated. For example, an aver-

age work unit with high civility may have reduced annual

EEO complaint costs of up to $61,000 per year and

reduced costs of approximately $250 per employee in use of

annual sick leave. Improved retention, productivity, and

quality outcomes also suggest possible savings. Furthermore,

lower mortality rates and decreased lengths of stay have been

documented in intensive care units with higher civility.

CREW success has led to expansion over the past few years,

with the initiative being extended to other VA and non-

government entities in the United States and Canada.

Table 2-1: Key Elements and Activities Associated with OSHA Components

of Worker Safety and Health Management Systems (continued)

Elements of a

Worker Safety

and Health

Management

System

Activities

Accident/

incident

investigation

• Training for incident investigation

• Six key questions should be answered: who, what, when, where, why, and how. Fact should be distin-

guished from opinion, and both should be presented carefully and clearly. The report should include thor-

ough interviews with everyone with any knowledge of the incident. A good investigation is likely to reveal

several contributing factors, and it probably will recommend several preventive actions.

• Information obtained through the investigation should be used to update and revise the inventory of haz-

ards, and/or the program for hazard prevention and control

Creating a

safety culture

• Obtain top management buy-in

• Build trust

• Conduct self assessments/benchmarking

• Establish a steering committee comprised of management, employees, union (if one exists), and

safety staff

• Develop site safety vision, key policies, goals, measures, and strategic and operational plans

• Align the organization by establishing a shared vision of safety and health goals and objectives

vs. production

• Define specific roles and responsibilities for safety and health at all levels of the organization

• Develop a system of accountability for all levels of the organization

• Develop measures and an ongoing measurement and feedback system

• Develop policies for recognition, rewards, incentives, and ceremonies. Again, reward employees for

doing the right things and encourage participation in the upstream activities.

• Continually measure performance, communicate results, and celebrate successes

• Ongoing support—reinforcement, feedback, reassessment, midcourse corrections, and ongoing training is

vital to sustaining continuous improvement

Adapted from source: Occupational Safety and Health Administration [Internet]. [cited 2012 Jan 31]. US Department of Labor; [about 1

screen]. Safety and Health Program Management: Fact Sheets. Available from: http://www.osha.gov/SLTC/etools/safetyhealth/mod4

_factsheets.html.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Table 2-2: Examples of Recommended Practices and Expectations Within

Patient Safety Programs Parallel to Those in Safety and Health

Management Systems for Workers

Elements of

Patient Safety

Program

Recommend-

ations and

Requirements

Recommended Activities from National Quality

Forum “Safe Practices for Better Healthcare”

Examples of Joint Commission Standards and

Elements of Performance for Hospitals

Leadership of

the system by

management

Safe Practice 1: Leadership Structures and

Systems

Leadership structures and systems must be estab-

lished to ensure that there is organizationwide

awareness of patient safety performance gaps,

direct accountability of leaders for those gaps, and

adequate investment in performance improvement

abilities, and that actions are taken to ensure safe

care of every patient served.

Safe Practice 9: Nursing Workforce

Implement critical components of a well-designed

nursing workforce that mutually reinforce patient

safeguards, including the following:

• A nurse staffing plan with evidence that it is ade-

quately resourced and actively managed and

that its effectiveness is regularly evaluated with

respect to patient safety

• Senior administrative nursing leaders, such as a

Chief Nursing Officer, as part of the hospital

senior management team

• Governance boards and senior administrative

leaders that take accountability for reducing

patient safety risks related to nurse staffing deci-

sions and the provision of financial resources for

nursing services

• Provision of budgetary resources to support

nursing staff in the ongoing acquisition and

maintenance of professional knowledge and

skills

Safe Practice 10: Direct Caregivers

Ensure that nonnursing direct care staffing levels

are adequate, that the staff are competent, and

that they have had adequate orientation, training,

and education to perform their assigned direct care

duties.

Standard LD.04.04.05 The hospital has an

organizationwide, integrated patient safety program

within its performance improvement activities.

LD.04.04.05, EP 1 The leaders implement a

hospitalwide patient safety program.

LD.04.04.05, EP 3 The scope of the safety pro-

gram includes the full range of safety issues, from

potential or no-harm errors (sometimes referred to

as near misses, close calls, or good catches) to

hazardous conditions and sentinel events.

LD.03.06.01, EP 3 Leaders provide for a suffi-

cient number and mix of individuals to support

safe, quality care, treatment, and services.

LD.04.04.05, EP 13 At least once a year, the

leaders provide governance with written reports on

the following:

• All system or process failures

• The number and type of sentinel events

• Whether the patients and the families were

informed of the event

• All actions taken to improve safety, both proac-

tively and in response to actual occurrences

• For hospitals that use Joint Commission accred-

itation for deemed status purposes: The deter-

mined number of distinct improvement projects

to be conducted annually

• All results of the analyses related to the ade-

quacy of staffing

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

Table 2-2: Examples of Recommended Practices and Expectations Within

Patient Safety Programs Parallel to Those in Safety and Health

Management Systems for Workers (continued)

Elements of

Patient Safety

Program

Recommend-

ations and

Requirements

Recommended Activities from National Quality

Forum “Safe Practices for Better Healthcare”

Examples of Joint Commission Standards and

Elements of Performance for Hospitals

Employee

involvement

Safe Practice 3: Teamwork Training and Skill

Building

Health care organizations must establish a proac-

tive, systematic, organizationwide approach to

developing team-based care through teamwork

training, skill building, and team-led performance

improvement interventions that reduce preventable

harm to patients.

LD.03.01.01, EP 3 Leaders provide opportunities for

all individuals who work in the hospital to participate in

safety and quality initiatives.

EC.03.01.01, EP 3 Staff and licensed independent

practitioners can describe or demonstrate how to

report environment of care risks.

Analysis of

hazards

Safe Practice 4: Identification and Mitigation of

Risks and Hazards

Health care organizations must systematically iden-

tify and mitigate patient safety risks and hazards

with an integrated approach in order to continu-

ously drive down preventable patient harm.

EC.02.01.01, EP 1 The hospital identifies safety and

security risks associated with the environment of care

that could affect patients, staff, and other people com-

ing to the hospital’s facilities.

Note: Risks are identified from internal sources such

as ongoing monitoring of the environment, results of

root cause analyses, results of annual proactive risk

assessments of high-risk processes, and from credi-

ble external sources such as Sentinel Event Alerts.

EC.02.02.01, EP 1 The hospital maintains a written,

current inventory of hazardous materials and waste

that it uses, stores, or generates. The only materials

that need to be included on the inventory are those

whose handling, use, and storage are addressed by

law and regulation.

EC.04.01.01 The hospital collects information to

monitor conditions in the environment.

Prevention

and control of

hazards

Safe Practice 19: Hand Hygiene

Comply with current Centers for Disease Control

and Prevention (CDC) Hand Hygiene Guidelines.

Safe Practice 20: Influenza Prevention

Comply with current CDC recommendations for

influenza vaccinations for health care personnel

and the annual recommendations of the CDC

Advisory Committee on Immunization Practices for

individual influenza prevention and control.

EC.02.01.01, EP 3 The hospital takes action to mini-

mize or eliminate identified safety and security risks in

the physical environment.

LD.04.04.03, EP 1 The hospital’s design of new or

modified services or processes incorporates the

needs of patients, staff, and others.

LD.04.04.05, EP 10 At least every 18 months, the

hospital selects one high-risk process and conducts a

proactive risk assessment.

IC.02.01.01, EP 1 The hospital implements its

Continued on next page

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Table 2-2: Examples of Recommended Practices and Expectations Within

Patient Safety Programs Parallel to Those in Safety and Health

Management Systems for Workers (continued)

Elements of

Patient Safety

Program

Recommend-

ations and

Requirements

Recommended Activities from National Quality

Forum “Safe Practices for Better Healthcare”

Examples of Joint Commission Standards and

Elements of Performance for Hospitals

Prevention and

control of

hazards

(continued)

infection prevention and control activities, including sur-

veillance, to minimize, reduce, or eliminate the risk of

infection.

IC.02.01.01, EP 2 The hospital uses standard pre-

cautions,* including the use of personal protective

equipment, to reduce the risk of infection.

* For further information regarding standard precautions, refer to the

Website of the Centers for Disease Control and Prevention (CDC) at

http://www.cdc.gov/hai/ (Infection Control in Healthcare Settings).

IC.02.03.01 The hospital works to prevent the trans-

mission of infectious disease among patients, licensed

independent practitioners, and staff.

IC.02.04.01 The hospital offers vaccination against

influenza to licensed independent practitioners and staff.

NPSG.07.01.01 Comply with either the current CDC

hand hygiene guidelines or the current World Health

Organization (WHO) hand hygiene guidelines.

Safety training Safe Practice 3: Teamwork Training and Skill

Building

Health care organizations must establish a proac-

tive, systematic organizationwide approach to

developing team-based care through teamwork

training, skill building, and team-led performance

improvement interventions that reduce preventable

harm to patients.

EC.03.01.01, EP 1 Staff and licensed independent

practitioners can describe or demonstrate methods for

eliminating and minimizing physical risks in the envi-

ronment of care.

LD.03.01.01, EP 6 Leaders provide education that

focuses on safety and quality for all individuals.

HR.01.05.03 Staff participate in ongoing education

and training

Accident/

incident

investigation

Safe Practice 4: Identification and Mitigation of

Risks and Hazards—Additional Specifications

Integrated Organizationwide Risk Assessment: The

continuous, systematic integration of the information

about risks and hazards across the organization

should be undertaken to optimally prevent systems

failures. Information about risks and hazards from

multiple sources should be evaluated in an

Continued on next page

LD.04.04.05, EP 6 The leaders provide and encour-

age the use of systems for blame-free internal report-

ing of a system or process failure, or the results of a

proactive risk assessment.

LD.04.04.05, EP 8 The hospital conducts thorough

and credible root cause analyses in response to sen-

tinel events.

Continued on next page

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

Table 2-2: Examples of Recommended Practices and Expectations Within

Patient Safety Programs Parallel to Those in Safety and Health

Management Systems for Workers (continued)

Elements of

Patient Safety

Program

Recommend-

ations and

Requirements

Recommended Activities from National Quality

Forum “Safe Practices for Better Healthcare”

Examples of Joint Commission Standards and

Elements of Performance for Hospitals

Accident/incident

investigation

(continued)

integrated way in order to identify patterns, systems

failures, and contributing factors involving discrete

service lines and units. The organization should inte-

grate the information noted below, ensure that it is

provided to those designing mitigation strategies

and that it is documented and disseminated widely

across the organization systematically and fre-

quently, and ensure that the results of mitigation

activities are made available to all who were

involved in providing source information.

LD.04.04.05, EP 11 To improve safety and to

reduce the risk of medical errors, the hospital ana-

lyzes and uses information about system or process

failures and the results of proactive risk assess-

ments.

Creating a safety

culture

Safe Practice 2: Culture Measurement,

Feedback, and Intervention

Health care organizations must measure their cul-

ture, provide feedback to the leadership and staff,

and undertake interventions that will reduce patient

safety risk.

Safe Practice 8: Care of the Caregiver

Following serious unintentional harm due to sys-

tems failures and/or errors that resulted from

human performance failures, the involved care-

givers (clinical providers, staff, and administrators)

should receive timely and systematic care to

include: treatment that is just, respect, compassion,

supportive medical care, and the opportunity to

fully participate in event investigation and risk iden-

tification and mitigation activities that will prevent

future events.

LD.03.01.01 Leaders create and maintain a cul-

ture of safety throughout the hospital.

LD.03.01.01, EP 1 Leaders regularly evaluate the

culture of safety and quality using valid and reliable

tools.

LD.03.01.01, EP 4 Leaders develop a code of

conduct that defines acceptable behavior and

behaviors that undermine a culture of safety.

LD.03.01.01, EP 5 Leaders create and implement

a process for managing behaviors that undermine a

culture of safety.

LD.03.01.01, EP 7 Leaders establish a team

approach among all staff at all levels.

LD.03.01.01, EP 8 All individuals who work in the

hospital, including staff and licensed independent

practitioners, are able to openly discuss issues of

safety and quality.

LD.04.04.05, EP 9 The leaders make support sys-

tems available for staff who have been involved in

an adverse or sentinel event. Note: Support systems

recognize that conscientious health care workers

who are involved in sentinel events are themselves

victims of the event and require support. Support

systems provide staff with additional help and sup-

port as well as additional resources through the

human resources function or an employee assis-

tance program. Support systems also focus on the

process rather than blaming the involved individuals.

Valuable Lessons

The improved cross-disciplinary communication (respectful,

clear, assertive) is seen to have a direct impact on the safety

of the work environment for staff and patients. Lessons

from six years of CREW implementation include the fol-

lowing:

• Participation by individual employees should not be

deemed mandatory, although behaving according to

CREW principles should be.

• CREW is workgroup based; it builds on relationships at

the workgroup level.

• It requires consistent, visible leadership support on all

levels.

• It is enhanced by full support and participation of labor

unions.

• It perpetuates by “viral spread.”

• Anecdotally, employees in CREW groups report stronger

trust, teamwork, resolution of problems/conflicts when

they occur, clearer understanding of connections to other

initiatives (for example, diversity, ethics, patient-centered

care, systems redesign, customer service, and learning

organization) and an increased awareness of their per-

sonal contribution to the mission of the organization.

• CREW is most successful when it is not thought of as

simply another program or initiative but the way busi-

ness is to be done.

Case Study References

* Osatuke K, Moore SC, Ward C, Dyrenforth SR, Belton L. Civility,

respect, engagement in the workforce (CREW): Nationwide

Organization Development Intervention at Veterans Health

Administration. J Appl Behav Sci. 2009 Sep 1;45(3):384–409.

† Garman AN, Corrigan PW, Morris S. Staff burnout and patient sat-

isfaction: evidence of relationships at the care unit level. J Occup

Health Psychol. 2002 Jul;7(3):235–241. PubMed PMID: 12148955.

2.2 Hierarchy of Controls: Example

of a Framework for Interventions to

Prevent Harm

Controlling exposures to occupational hazards is a funda-

mental method of protecting workers. After workplace haz-

ards have been identified, the obvious subsequent step is to

mitigate them. Industrial hygienists have created a very help-

ful framework for developing interventions and deciding

which prevention methods to implement. This framework is

known as the hierarchy of controls.

It lists, in decreasing

order of efficacy, the general control methods that should be

applied to resolve hazardous situations. In many cases, a

combination of control methods will be applied, but the

expectation is that each control type will be considered in a

sequential fashion and in a descending order. All reasonable

attempts should be made to use the more-effective steps

higher in the hierarchy before lower steps are considered. A

lower step should not be chosen until practical applications

of the preceding higher levels are exhausted.

Although the hierarchy of controls varies slightly among dif-

ferent countries and different organizations, it generally fol-

lows the structure described in Table 2-3.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Table 2-3: Hierarchy of Controls

Control Type Description

Elimination A control that removes the hazard from the work process

Substitution

A control in which a less hazardous or nonhazardous substance or process is

used in place of the original hazard

Engineering Controls that isolate the hazard from the worker

Administrative or

Work Practices

Practices and policies employed by an organization to limit an employee’s

exposure to a hazard.

Personal Protective

Equipment

Special equipment designed to prevent workers from coming into contact

(via inhalation, ingestion, or absorption) with a hazardous substance.

Adapted from source: Milz SA. Principles of evaluating worker exposure. In: The Occupational Environment: Its Evaluation, Control and

Management. Falls Church (VA): American Industrial Hygiene Association, 2011.

Increasing

Effectiveness of Control

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

There is no direct association between the level of control

and the cost of the intervention. Costs vary depending on

the variables under consideration. For example, designing

a mistake-proof system to prevent exposure to a hazardous

chemical or radiation may require a large upfront invest-

ment, and the long-term savings to workers and patients

may make the innovation highly cost effective. The

National Institute for Occupational Safety and Health

(NIOSH) recommends that elimination and substitution

be addressed during the design and development phases of

a project, because it is often more difficult and expensive

to apply these controls to existing processes and systems.

While administrative controls and personal protective

equipment (PPE) or behavior change may have lower

upfront costs, the effort and resources required to main-

tain these controls over the long run can become quite

expensive.

Though the hierarchy of controls principle was initially

developed and applied to worker safety issues, it is applica-

ble to patient safety as well. Table 2-4 provides examples of

controls applied at each level for worker and patient safety.

In practice, preventing hazards and accidents for both work-

ers and patients often requires a combination of controls

applied at all levels.

2.3 Human Factors and Safer Design

“Trying harder will not work. Changing systems will.” So

says the IOM in Crossing the Quality Chasm: A New Health

System for the 21st Century.

The scientific fields of human factors, ergonomics, and safer

engineering of work processes and the built environment all

contribute potential solutions to improving safety for

patients and workers. The sections that follow provide a

Table 2-4: Examples of Controls in Worker and Patient Safety

Control Worker Safety Examples Patient Safety Examples

Examples for Both

Workers and Patients

Elimination Immunization against

Hepatitis B

Designing tubing connections

so they cannot fit other ports

Removal of latex-based prod-

ucts to prevent sensitization

and allergic reactions

Substitution Digital imaging instead of wet

chemicals; microfiber mops

instead of conventional mops

Substituting bottles of con-

centrated potassium chloride

on nursing units with premea-

sured unit dose vials

Slip-resistant floors; changing

from germicide spray solu-

tions to wipes to reduce

aerosolized respiratory irri-

tants

Engineering controls Ventilated cabinets for com-

pounding of chemotherapy

drugs in pharmacy, safety

engineered sharp devices,

blunt suture needles, patient

lifting equipment; MRI control

rooms

Bar-coded patient identifica-

tion bands for medication

administration systems;

“smart pumps” for intra-

venous infusions; RFID

sponge counters technology

Isolation rooms with negative

pressure ventilation to reduce

transmission of airborne

pathogens; separated decon-

tamination units

Administrative and

organizational controls

Staffing levels, staff rotation,

standard or contact precau-

tions, training

Checklists for central line

insertions; time-out prior to

surgery; competency testing,

daily huddles; pharmacy

rounds

Customize staffing mix and

level based on patient/resi-

dent acuity or needs; monitor

hand hygiene

Personal Protective

Equipment and individual-

level behaviors, responses

Gloves, goggles, respirators,

masks, hand hygiene;

Hepatitis B and related immu-

nizations

Hand hygiene, gowns,

gloves, masks, immunization

Influenza immunization;

tuberculosis infection testing

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

brief introduction to the topic areas and resources for fur-

ther information.

2.3.1 Human Factors

Human factors science is a broad discipline that studies the

relationship between human behavior, system design, and

safety.

The World Health Organization (WHO) describes

human factors as inclusive of environmental, organizational,

and job factors in combination with the human and indi-

vidual characteristics that influence behavior at work in a

way that can affect health and safety. It is broken down into

three aspects—the job, the individual, and the organiza-

tion—and how they impact people’s health and safety-

related behavior.

Another definition of human factors is

“the application of scientific knowledge about human

strengths and limitations to the design of systems in the

work environment to ensure safe and satisfying perform-

ance.”

Outside of health care, human factors research and engi-

neering has a prominent role in high risk industries such as

aerospace and nuclear power. For example, the Federal

Aviation Administration has invested heavily in human fac-

tors research and development regarding flight deck activi-

ties and air traffic control operations.

An aviation-based

intervention to improve safety by enhancing teamwork

called “Crew Resource Management” has also been success-

fully applied in health care.

19,20

Adopting a systems perspective is a key element of the

National Research Council’s Board on Human-Systems

Integration. This board serves to provide new perspectives

on theoretical and methodological issues concerning the

relationship of individuals and organizations to technology

and the environment; identifies critical issues in the design,

testing, evaluation, and use of new human-centered tech-

nologies; and advises sponsors on the research needed to

expand the scientific and technical bases for designing tech-

nology to support the needs of its users.

Information from

a report on human factors issues in home health care is

described in the next resource table.

Those who study root causes of errors in health care find

that human factors often contribute to adverse events for

patients. Many of these same factors also contribute to

adverse events for workers. Figure 2-3, page 37, provides an

overview of the many factors that contribute to adverse

events. The factors lie along a continuum, from latent con-

ditions, which often lie dormant and hidden in the organi-

zation, to active errors committed by health care providers

during the care process. A complete explanation of the fac-

tors at each tier is found in the Agency for Healthcare

Research and Quality (AHRQ) publication titled Patient

Safety and Quality: An Evidence-Based Handbook for Nurses.

2.3.2 Ergonomics

Ergonomics is the science of fitting workplace conditions

and job demands to the capabilities of the working popula-

tion.

According to OSHA, a good fit between employee

capabilities, workplace conditions, and job demands helps

ensure high productivity, avoid illness and injury, and

increase satisfaction in the workforce. This, in turn, should

translate to higher quality patient care and fewer adverse

events for workers and patients.

Much of the ergonomic work in health care has been

focused on preventing or alleviating musculoskeletal disor-

ders (MSDs). Common examples of ergonomic risk factors

are found in jobs requiring repetitive, forceful, or prolonged

exertions of the hands; frequent or heavy lifting, pushing,

pulling, or carrying of heavy objects; and prolonged awk-

ward postures. Vibration and cold may add risk to these

work conditions. Jobs or working conditions presenting

multiple risk factors will have a higher probability of causing

a musculoskeletal problem. The level of risk depends on the

intensity, frequency, and duration of the exposure to these

conditions and the individual’s capacity to meet the force of

other job demands that might be involved.

See Chapter 3

for additional information on ergonomic health care inter-

ventions to reduce MSDs.

Strategies to better fit workplace conditions and job

demands to worker capabilities fall into the following three

categories related to the hierarchy of controls; examples for

each category are shown in Sidebar 2-1, page 38:

1) Administration/management/leadership

2) Equipment/engineering/environmental

3) Health care worker/patient/other individuals

The importance of human factors and ergonomics in

improving safety continues to grow. A recent article suggests

that the patient safety field has failed to recognize the need

to include human factors and ergonomics in solutions and

interventions. It recommends expanded training for clini-

cians as well as increased pressure on manufacturers to

incorporate human factors and ergonomic principles and

techniques.

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

Figure 2-3: Contributing Factors to Adverse Events in Health Care

Source: Henriksen K, et al. Understanding adverse events: A human factors framework. In Hughes RG, editor. Patient Safety and Quality: An

Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US), 2008 Apr. Chapter 5. Available

from: http://www.ncbi.nlm.nih.gov/books/NBK2666/.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

2.3.3 Safer Design of Work Processes

The goal of redesign (or reengineering) of work processes for

safety is to make it harder to do the wrong thing and easier

to do the right thing. Redesign has been shown to be more

effective in decreasing errors than other interventions such

as education, incentives, and threats.

24,25

Simplification and

standardization of processes across different areas are key ele-

ments in redesign. The probability that a process will fail is

directly related to the number of steps and lack of consis-

tency in the process across providers.

Simplification and

standardization are particularly important for processes that

are high risk for patients and/or for workers. Examples of

standardization include central line–insertion supply kits or

carts, use of metered dispensers of premixed cleaning chemi-

cals, and use of standard precautions to prevent transmission

of infections.

An organization’s first step in safer process design is map-

ping its current processes to identify opportunities for

improvement. The Institute for Healthcare Improvement

(IHI) offers free tools and instructions for this activity.

is important also to observe the actual implementation of

the process at various points in time to determine where

and how errors occur. Redesign considerations can also

address the interface between products and users; the

choice of processes, materials, and equipment; work organi-

zation and policies; and the physical environment. Figure

2-4, page 39 shows an example of a flowchart algorithm for

safe patient transfer.

The scale of redesign can be small or large. In some cases,

redesigns can eliminate the errors entirely; in others, redesign

can reduce the frequency or mitigate the impact of errors.

For example, during the 1990s, there were many deaths asso-

ciated with accidental administration of concentrated potas-

sium chloride.

A process redesign that required removal of

concentrated potassium chloride from a unit’s floor stock led

to substantial reduction in this sentinel event.

A simple

process redesign example to prevent sharps injuries is hands-

free transfer of surgical instruments using a tray.

A free toolkit and case example of redesign at the health care

system level applied by Denver Health is available from

AHRQ.

2.3.4 Preventing Harm Through Safer Design

of the Built Environment

Understanding the effect of architectural and engineering

design, construction, and maintenance (both exterior and

Sidebar 2-1: Examples of

Strategies to Better Fit

Workplace Conditions and Job

Demands to Worker Capabilities

Strategies to better fit workplace conditions and job

demands to employee capabilities fall into three cate-

gories. This sidebar shows examples of what can be

done to ensure patient/worker safety for each category.

1) Administration/management/leadership

• Demonstrate a commitment to reduce or eliminate

patients/residents handling hazards through estab-

lishing a written program

• Provide continued training of employees in injury

prevention and use of assistive devices

• Clarify methods of transfer and lifting to be used

by all staff and importance of proper technique

• Monitor compliance with transfer and lift proce-

dures

• Establish and educate staff on procedures for

reporting unsafe working conditions and early

signs and symptoms of back pain and other mus-

culoskeletal injuries

• Provide for adequate staffing, assessment of

patient’s/resident’s needs, and restricted admit-

tance policies

• Conduct a workplace analysis using observations,

surveys, and staff interviews to identify hazards

2) Equipment/engineering/environmental

• To prevent MSDs and falls, provide assistive

devices or equipment such as mechanical lift

equipment, sliding boards, repositioning devices,

shower chairs, walking belts, and the like

• To prevent infections and improve hand hygiene

adherence to guidelines, conveniently locate sinks

and alcohol-based hand rubs at room entrances

• To prevent sharps injuries, use safety-engineered

sharp devices

3) Health care worker/patient/other individuals

• Report unsafe working conditions to management

• Promptly report MSD signs and symptoms as well

as injuries to occupational health

• Follow procedures for lifting and use of equipment

Adapted from source: Occupational Safety and Health

Administration [Internet]. [cited 2012 Jan 31]. US Department of

Labor; [about 10 screens]. Healthcare Wide Hazards:

Ergonomics. Available from: http://www.osha.gov/SLTC

/etools/hospital/hazards/ergo/ergo.html.

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

interior) on safety practices is an emerging scientific field

with much promise. As shown in the hierarchy of controls,

the most effective way of hazard mitigation is via elimina-

tion. This is best accomplished during the design process.

NIOSH is leading a national initiative called “Prevention

through Design” (PtD) to promote “addressing occupational

safety and health needs in the design process to prevent or

minimize the work-related hazards and risks associated with

the construction, manufacture, use, maintenance, and dis-

posal of facilities, materials, and equipment” and highlight

the importance to worker safety of preventing or minimiz-

ing these hazards and risks.

Figure 2-4: Sample Flow Chart

Source: US Department of Veteran Affairs [Internet]. Algorithms for Safe Patient Handling and Movement. Available from: VISN 8 Partner

Safety Center of Inquiry. Tampa, FL. VA Sunshine Healthcare Network, Safe Patient Handling and Movement. http://www.visn8.va.gov

/visn8/patientsafetycenter/safePtHandling/default.asp.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Another prominent organization involved with safer design

is Health Care Without Harm (HCWH), an international

coalition of hospitals and health care systems, medical pro-

fessionals, community groups, health-affected constituen-

cies, labor unions, occupational and environmental health

organizations, and religious groups. Adhering to the oath of

“first do no harm,” partnering organizations are working to

implement ecologically sound and healthy alternatives to

health care practices that pollute the environment and con-

tribute to disease.

Together with the Center for Maximum

Potential Building Systems, HCWH has released the Green

Guide for Health Care, which is a toolkit providing quantifi-

able and sustainable design, construction, and operations

techniques customized for the health care sector. Using these

techniques will help health care organizations build facilities

that are more healthful for people, workers, patients, and

visitors alike—and better for the environment.

Recently, more than 500 leading hospitals committed to a

new campaign known as the Healthier Hospitals Initiative.

This three-year campaign will focus on the following tasks:

• Engaging in leadership on environmental health and

sustainability

• Serving more healthful foods and beverages

• Reducing energy use

• Reducing waste and increasing recycling

• Using safer chemicals

• Purchasing environmentally preferable products

On the patient safety side, two organizations have been at the

forefront of addressing safety through design. The Center for

Health Design (CHD) was formed in 1993 with a mission to

transform health care environments for a healthier, safer world

through design research, education, and advocacy.

The

Robert Wood Johnson Foundation has supported the develop-

ment of evidence that demonstrates that safer design is effec-

tive. For example, a paper by Ulrich and Barach describes

potential uses of design to prevent harm related to areas such

as noise, medication and data entry errors, healthcare–associ-

ated infections, falls, and intrafacility handoffs and transfers.

AHRQ and the Facilities Guidelines Institute convened a

national seminar in October 2011 to address the role of the

built environment in improving patient safety.

Among the

recommendations that emerged was the need to develop an

explicit vision for patient safety in the predesign phase and

to conduct risk assessments for patient safety and infection

control. A risk-assessment tool is under development by a

subgroup of meeting participants.

The built environment includes not only inpatient facilities

like hospitals and nursing homes but also the environments

for nonfacility-based health care services such as home

health care. A recent report published by the National

Academies of Sciences and AHRQ entitled “Health Care

Comes Home: The Human Factors” describes the impact of

technology, environment, policy, and human factors on the

growing field of home health care. It includes information

on what devices and tools are available, the impact of health

information technology, and the ways different cultures

approach home health care. It also offers recommendations

to ensure quality health care in the home.

2.4 Improving Performance Through

Incident Reporting and Feedback

Systems

The past several decades have witnessed a surge in para-

digms, strategies, and tools to improve performance in

health care. Various models of quality improvement have

been applied in health care settings, including the well-

known cycle of “plan-do-study-act, or “PDSA.”

39,40

recently, The Joint Commission has proposed the model of

Robust Process Improvement (RPI).

RPI combines con-

cepts from the industrial models of Lean and Six Sigma

(which includes the phases of define, measure, analyze,

improve, and control known as “DMAIC”) with change

management methodologies and tools for helping organiza-

tions achieve high reliability.

Structured process improve-

ment models such as these provide a systematic approach to

solving complex problems and help guide improvement

teams to examine why processes fail to achieve their desired

results.

Regardless of the method selected and tools used for quality

improvement, opportunities to coordinate patient and

worker safety improvement should be identified and

explored for data that support combined patient/worker

health and safety issues. Take, for example, the case of a hos-

pital that has a quality improvement initiative to report and

analyze patient falls. This initiative includes reporting of

“near-miss” falls in which the patient did not actually get

hurt. A root cause analysis of these events might reveal that

workers are getting injured instead because of their efforts to

prevent patients from falling. A multidisciplinary team may

be able to identify solutions that prevent injury to patients

and workers simultaneously. This example also highlights

the value of having frontline staff participate directly in the

design and planning stages of safety reporting systems and

improvement activities.

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

Resources 2-1: Human Factors and Safer Design

Title and Website Description

Agency for Healthcare Research and Quality (AHRQ)

Publication

Mistake-Proofing the Design of Health Care Processes; AHRQ

Publication No. 07-0020, May 2007

http://www.ahrq.gov/qual/mistakeproof/mistakeproofing.pdf

This volume represents a compendium of informa-

tion and ideas to broaden the reader’s understand-

ing of mistake proofing and its emerging role in

health care and patient safety.

DVD

Transforming Hospitals: Designing for Safety and Quality; AHRQ

Publication No. 07-0076-DVD, September 2007

http://www.ahrq.gov/qual/transform.htm

This DVD examines the case for evidence-based

hospital design and how it strengthens patient and

staff satisfaction and safety, quality of care, and

employee retention, and results in a positive return

on investment.

Handbook

Henriksen K, Dayton E, Keyes MA, Carayon P, Hughes R. Chapter 5:

Understanding Adverse Events: A Human Factors Framework

(http://www.ncbi.nlm.nih.gov/books/n/nursehb/ch5/)

Stone PW, Hughes R, Dailey M. Chapter 21: Creating a Safe and High-

Quality Health Care Environment

(http://www.ncbi.nlm.nih.gov/books/NBK2634/)

Reiling J, Hughes RG, Murphy MR. Chapter 28: The Impact of Facility

Design on Patient Safety (http://www.ncbi.nlm.nih.gov/books/NBK2633/)

Hughes RG, editor. Patient Safety and Quality: An Evidence-Based

Handbook for Nurses [Internet]. Rockville (MD): Agency for Healthcare

Research and Quality (US); [updated 2008 Apr; cited 2012 Jan 30].

Available from: http://www.ahrq.gov/qual/nurseshdbk/

This free online publication presents a wealth of

information about improving safety and the work

environment, not only for nurses but for all who

work in health care settings.

American Industrial Hygiene Association

(AIHA

)

Website

AIHA reference document to employers and employees regarding

ergonomics.

http://www.aiha.org/news-pubs/govtaffairs/Documents/Ergonomics

%20Reference%20Document-11-10-11.pdf

This site directs you to an ergonomics reference

document. AIHA

adopted its first position state-

ment on the issue of ergonomics in 1997. AIHA

has amended this position statement on several

occasions, most recently in October 2009. AIHA

believes information should be made available to

assist employers and employees in developing

guidelines or otherwise addressing ergonomics

concerns.

Centers for Disease Control (CDC) – National Institute for Occupational Safety and Health (NIOSH)

Website

Prevention through Design

http://www.cdc.gov/niosh/topics/ptd/

A NIOSH-led national initiative called Prevention

through Design (PtD) to promote a concept to

“design out” or minimize hazards and risks early in

the design process. It highlights its importance in

all business decisions.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Resources 2-1: Human Factors and Safer Design (continued)

Title and Website Description

Centers for Disease Control (CDC) – National Institute for Occupational Safety and Health (NIOSH) [continued]

Publication

A Primer Based on Workplace Evaluations of Musculoskeletal Disorders

http://www.cdc.gov/niosh/docs/97-117/

This publication describes the basic elements of a

workplace program aimed at preventing work-

related musculoskeletal disorders (WMSDs). It

includes includes a “toolbox,” which is a collection

of techniques, methods, reference materials, and

sources for other information that can help in pro-

gram development.

Publication

The Changing Organization of Work and the Safety and Health of

Working People

http://www.cdc.gov/niosh/docs/2002-116/

This publication discusses sweeping changes in

the organization of work that have been influenced

by major economic, technological, legal, political,

and other forces.

Publication

Fisher JM. Rapporteur’s Report: Healthcare and Social Assistance

Sector. Journal of Safety Research. 2008 Mar 14;39(2):179–181.

Available from: http://www.cdc.gov/niosh/topics/ptd/pdfs/Fisher.pdf.

This paper describes key implementation issues

and specific needs, challenges, and opportunities

from the Prevention through Design (PtD) initiative

in the following areas: practice, research, policy,

and education.

Report

Quinn M, Pentecost R III, Fisher J, and Hughes N.

Chapter 8: Healthy Healthcare Design.

In: US Department of Health and Human Services, Centers for Disease

Control and Prevention, National Institute for Occupational Safety and

Health [Internet]. State of the Sector | Healthcare and Social Assistance:

Identification of Research Opportunities for the Next Decade of NORA.

DHHS (NIOSH) Publication Number 2009-139. Available from:

http://www.cdc.gov/niosh/docs/2009-139.

This chapter reviews the literature and state of the

science related to design and ergonomic issues in

health care.

Center for Health Design

Conference Paper

Cohen G. “First do no harm,” Designing the 21st Century Hospital:

Environmental leadership for healthier patients and facilities. Center for

Health Design, RWJF, 2006.

http://www.healthdesign.org/chd/research/first-do-no-harm

This paper was presented by The Center for

Health Design (CHD) and Health Care Without

Harm (HCWH) at a conference sponsored by the

Robert Wood Johnson Foundation, September

2006. The paper explores the implications of this

new science linking contaminants and health and

discusses the environmental innovations that hos-

pitals are implementing to not only create more

optimal conditions for healing in their institutions

but also to prevent disease in the general public.

Report

Designing for Patient Safety: Developing Methods to Integrate Patient

Safety Concerns in the Design Process

Anjali Joseph, PhD, EDAC (Principal Investigator)

http://www.healthdesign.org/sites/default/files/chd416_ahrqreport_final.pdf

This is the final report of an AHRQ-supported proj-

ect initiated for the following: to develop consensus

around important patient safety issues to be con-

sidered during various stages in the healthcare

design process and to identify key activities,

methodologies, and tools for improving facility

design in terms of patient safety.

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

Resources 2-1: Human Factors and Safer Design (continued)

Title and Website Description

Facility Guidelines Institute

Publication

Guidelines for Design and Construction of Health Care Facilities

http://www.fgiguidelines.org

The Guidelines for Design and Construction of

Health Care Facilities recommends minimum pro-

gram, space, functional program, patient handling,

infection prevention, architectural detail, and sur-

face and furnishing needs for clinical and support

areas of hospitals, ambulatory care facilities, reha-

bilitation facilities, and nursing and other residential

care facilities.

Institute for Healthcare Improvement (IHI)

School for Health Professionals

IHI Open School Exercise on Identifying Human Factors in Health Care

http://www.ihi.org/offerings/ihiopenschool/resources/Pages/Tools

/ExerciseHumanFactors.aspx

An exercise that allows the participant to analyze

everyday situations to determine what human fac-

tors issues are at play and decide what interven-

tions should be introduced to minimize the

opportunities for mistakes.

Joint Commission Resources

Workshop

Safe Health Design Learning Academy

http://www.jcrinc.com/SHD-Pilot-Program/

This site links the reader to an experiential work-

shop for clinical leaders impacting health care con-

struction. The goal of the initiative is to provide the

information, resources, and support needed by

clinical leaders/decision makers to create evidence-

based health care facilities that will support people

and processes, now and into the future.

National Research Council

Report Brief

Health Care Comes Home: The Human Factors. Washington (DC): The

National Academies Press; 2011.

http://www7.nationalacademies.org/dbasse/Report_Brief_Health_Care

_Comes_Home_The_Human_Factors.pdf

As described in the report brief, the safety, quality,

and effectiveness of home health care can be

informed by many issues encompassed by the field

of human factors research and practice—which stud-

ies human capabilities and limitations and their inter-

action with the design of products, processes,

systems, and work environments. For that reason,

the AHRQ asked the Board on Human-Systems

Integration of the National Research Council to con-

duct a systematic investigation of the role of human

factors in home health care. In response, the multi-

disciplinary Committee on the Role of Human

Factors in Home Health Care was formed to exam-

ine a diverse range of behavioral and human factors

issues resulting from the increasing migration of

medical devices, technologies, and care practices

into the home. Its goal was to lay the groundwork for

a thorough integration of human factors, knowledge,

and research with the design and implementation of

home health care devices, systems, technologies,

and practices.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Chapter 3 provides examples of topic areas in which

improvement activities will directly benefit patients and

workers. Identifying high-priority health and safety issues

that impact workers and patients at an organization can be

supported by looking across existing performance measure-

ment and data collection systems. Continued measurement

is critical to evaluating the impact (and hopefully improve-

ment) of a quality initiative. It may be possible to work with

information technology staff to interrelate patient safety and

employee safety and health data reporting and analysis sys-

tems. Linkages could be used to monitor the impact of

interventions targeted toward either patients or workers on

outcomes for both groups to identify benefits as well as

unintended negative consequences. This can help build a

baseline of evidence for assessing the combined impact of

safety problems as well as the dual benefit of improvements.

Finally, financial data sources (patient and employee) may

provide information about baseline costs, both direct and

indirect, and changes over time in response to improvement

interventions.

2.4.1. Sources for Outcome Data on Worker

and Patient Safety

Data on occupational injury and illness are collected and

reported under OSHA regulations, which require that

organizations use the Log of Work-Related Injuries and

Illnesses (Form 300) to list acute injuries and illnesses and

track days away from work, restricted work activity, or job

transfer (also known as Days Away, Restrictions and

Transfers, or DART).

Other available forms from OSHA

Resources 2-1: Human Factors and Safer Design (continued)

Title and Website Description

Publications

Carroll JS, Rudolph JW. Design of high reliability organizations in health

care. Qual Saf Health Care. 2006;15(Suppl 1):i4–i9.

Reiling JG, Knutzen BL, Wallen TK, McCullough S, Miller R, Chernos S.

Enhancing the traditional hospital design process: A focus on patient

safety. Jt Comm J Qual Saf. 2004 Mar;30(3):115-124. Erratum in: Jt

Comm J Qual Saf. 2004 May;30(5):233. PubMed PMID: 15032068.

Ulrich R, Zimring C, Quan X, Joseph A, Choudhary R. The Role of the

Physical Environment in the Hospital of the 21st Century: A Once-in-a-

Lifetime Opportunity. Princeton (NJ): Robert Wood Johnson Foundation;

2004.

These articles provide information about environ-

mental design and safety.

The Joint Commission

White Paper

Health Care at the Crossroads: Guiding Principles for the Development

of the Hospital of the Future

http://www.jointcommission.org/assets/1/18/Hosptal_Future.pdf

This white paper addresses broad issues relating to

the provision of safe, high-quality health care and,

indeed, the health of the American people. The

white paper represents the culmination of a round-

table discussion. Proposed principles for guiding

future hospital development are summarized.

Washington State Department of Labor and Industries and Puget Sound Human Factors and Ergonomics Society

Examples of Costs and Benefits of Ergonomics

http://www.pshfes.org/Resources/Documents/Ergonomics_cost_benefit

_case_study_collection.pdf

An annotated bibliography of case studies and

reports describing sources, interventions, costs,

measurements, and savings on ergonomic inter-

ventions across industries. Includes more than 40

studies related to health care ergonomics.

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

include the Injury and Illness Report (Form 301) to record

supplementary information about recordable cases and the

Summary (Form 300A) to show totals for the year in each

category. Tracking rates and trends such as DART provides

important outcome data on employee safety and health. In

addition to occupational health, other sources for worker

data within an organization may include the departments of

employee health, human resources, infection prevention,

risk management, and quality improvement.

Examples of existing sources within health care organiza-

tions for patient safety outcome data include morbidity and

mortality conferences, risk management and sentinel event

reports, and performance measure data required for external

reporting to government and private organizations.

2.4.2 Incident Surveillance, Reporting,

Analysis, and Feedback

Another example of parallel worker and patient safety-

related activities is incident identification and management.

Incident reporting systems were originally developed in

industries in which safety was critical, such as the airline and

nuclear power industries. The underlying concept of inci-

dent reporting systems is that reporting and investigation of

individual events, and “near misses” or “close calls” can gen-

erate useful information to identify opportunities for

improvement in local systems and processes.

The application of incident reporting systems to patient

safety grew rapidly after publication of the IOM report “To

Err Is Human: Building a Safer Health System.”

Aggregating and reporting incidents to external organiza-

tions that maintain a centralized database can lead to identi-

fication of new hazards, trends, and potential strategies for

solutions; these solutions can then be shared broadly to pre-

vent incidents from occurring elsewhere. This is the concept

behind the Patient Safety and Quality Improvement Act of

2005 (Patient Safety Act) that led to the development of

Patient Safety Organizations (PSOs).

These organizations

are public or private entities that create a secure environ-

ment in which clinicians and health care organizations can

collect, aggregate, and analyze data, thereby improving qual-

ity by identifying and reducing the risks and hazards associ-

ated with patient care.

Effective incident reporting and feedback systems have many

steps in common. As described by Benn and colleagues,

there

are nine stages within the safety feedback loop that contribute

to the system success (see Figure 2-5, page 46).

In its “Draft Guidelines for Adverse Event Reporting and

Learning Systems,” WHO identified the following four core

principles underlying its guidelines

• The fundamental role of (patient) safety reporting sys-

tems is to enhance (patient) safety by learning from fail-

ures of the health care system.

• Reporting must be safe. Individuals who report incidents

must not be punished or suffer other ill effects from

reporting.

• Reporting is only of value if it leads to a constructive

response. At a minimum, this entails feedback of find-

ings from data analysis. Ideally, it also includes recom-

mendations for changes in processes and systems of

health care.

• Meaningful analysis, learning, and dissemination of

lessons learned require expertise and other human and

financial resources. The agency that receives reports

must be capable of disseminating information, making

recommendations for changes, and informing the

development of solutions.

Clearly, the value of incident/event reporting systems derives

from going beyond reporting to include analyzing, investi-

gating, identifying and implementing solutions, and moni-

toring the effectiveness of those solutions.

Despite the long history of incident reporting systems, the

ability to reap the full benefit of such systems remains elu-

sive. Experience in the field with both worker and patient

safety reporting systems has identified significant challenges

at each step.

48–50

For example, some employers establish

safety programs that unintentionally reward their employees

for not reporting errors or injuries, such as bonuses or par-

ties when an injury-free period is completed.

Although

these employers may be able to boast of days without a

reported error or injury, their patients or employees may

actually be injured. Negative peer pressure or the desire to

“win” or be a “team player” may cause the employees to

underreport errors or injuries.

With substantial effort and effective strategies to over-

come legal (such as variation in tort laws), practical (such

as time constraints), and attitudinal barriers (such as fear

of blame), organizations have been able to increase report-

ing of incidents. For example in 2003, England and Wales

established a National Reporting and Learning System for

collecting and analyzing data on patient safety incidents.

Reporting has steadily increased over time, and researchers

have found that hospitals with more positive data on stan-

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

dardized safety culture surveys were more likely to report

events. Moreover, these events included a lower propor-

tion of slips, trips, and falls. This suggests that reporting

of more events is associated with safer hospitals instead of

the converse.

Nevertheless, analysis, feedback, and

implementation of effective solutions often remain an

enormous challenge in health care organizations, for both

patient and worker safety systems.

2.4.2.1 Examples of Injury and Illness Tracking Systems

for Workers and Patients

Following are examples of national surveillance and per-

formance measurement systems, either electronic and/or

manual that can be used to track health care–associated

injuries, illnesses, hazards, and exposures and gain compara-

tive information.

• CDC National Healthcare Safety Network (NHSN)

The NHSN is a secure, Internet-based surveillance sys-

tem that expands and integrates former CDC surveil-

lance systems, including the National Nosocomial

Infections Surveillance (NNIS) System, National

Surveillance System for Healthcare Workers (NaSH),

and the Dialysis Surveillance Network (DSN).

NHSN enables health care facilities to collect and use

data about health care–associated infections, adherence

to clinical practices known to prevent health care–associ-

ated infections, the incidence or prevalence of multidrug-

resistant organisms within their organizations, trends

and coverage of health care personnel safety and vaccina-

tion, and adverse events related to the transfusion of

blood and blood products.

The NHSN comprises the following four components:

patient safety, health care personnel safety, research and

development, and biovigilance. The majority of acute

care hospitals are now required to submit data to the

NHSN patient safety module to comply with states and

Centers for Medicare & Medicaid Services quality

reporting initiatives.

• NHSN Healthcare Personnel Safety Component

In the 1990s the CDC developed the NaSH, which

Figure 2-5: Feedback Loop for Safety Incidents

Source: Benn J, Koutantji M, Wallace L, Spurgeon P, Rejman M, Healey A, Vincent C. Feedback from incident reporting: Information and

action to improve patient safety. Qual Saf Health Care. 2009 Feb;18(1):11–21. Review. PubMed PMID: 19204126. Used with permission.

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

focused on surveillance of exposures and infections

among health care personnel. Operational from 1995

through 2007, NaSH has been replaced by the

Healthcare Personnel Safety Component of the NHSN.

The component consists of the following four modules:

(1) Blood/Body Fluids Exposure with Exposure

Management, (2) Blood/Body Fluids Exposure only,

(3) Influenza Exposure Management, and (4) Influenza

Vaccination Summary Module.

• NHSN Patient Safety Component

Instructions and standardized surveillance methods and

definitions are fundamental to the specific types of sur-

veillance within the Patient Safety Component outlined

below:

– Device-associated module:

■

CLABSI - Central line–associated bloodstream

infection

■

CLIP - Central line–insertion practices

adherence

■

VAP - Ventilator-associated pneumonia

■

CAUTI - Catheter-associated urinary tract

infection

■

DE - Dialysis Event

– Procedure-associated module:

■

SSI - Surgical-site infection

■

PPP - Postprocedure pneumonia

– Medication-associated module:

■

AUR - Antimicrobial use and resistance

options

– Multidrug-resistant Organism/Clostridium difficile

Infection (MDRO/CDI) module

– Vaccination module

• NIOSH Surveillance Systems

NIOSH funds and conducts research on surveillance

methods and conducts surveillance activities to fill

gaps in existing surveillance data and define future

research priorities. For example, NIOSH has a system

of surveillance for some occupational respiratory dis-

eases, and it analyzes national health surveys to detect

patterns and trends of respiratory disease within occu-

pations and industries. NIOSH maintains the Work-

Related Injury Statistics Query System (Work-RISQS)

for national information on nonfatal occupational

injuries associated with visits to hospital emergency

rooms. For more information on these NIOSH

activities visit http://www.cdc.gov/niosh/programs

/surv/

NIOSH plans to implement a new surveillance system

to monitor occupational injuries to health care workers,

called the Occupational Health and Safety Network

(OHSN). The aim of the OHSN is to identify effective

prevention strategies and help health care facilities

implement them in their own practices—these injuries

can range from slips, trips, and falls; workplace violence;

and physical overexertion. The benefits of this program

will include (but is definitely not limited to) the follow-

ing:

– Benchmarking rates and trends against data from

similar facilities

– Comparing patterns of injuries and circumstances

leading to those injuries

– Identifying effective intervention approaches shared

by NIOSH and other OHSN participating facilities

Open enrollment for OHSN is planned to begin around

end of 2012 to the beginning of 2013.

• National Database of Nursing Quality Indicators

(NDNQI)

Some professional organizations have comparative per-

formance measurement systems that include data for

both workers and patients. For example, the American

Nurses Association NDNQI provides its participating

members with individual and comparative performance

data on topics such as:

– Patient falls and falls with injury

– Pressure ulcers (hospital acquired and unit acquired)

– Physical/sexual assault

– Staff mix (registered nurses [RNs] licensed

practical/vocational nurses [LPN/LVNs], unlicensed

assistive personnel [UAP])

– Nursing care hours provided per patient day

– Nurse turnover

– RN education/certification

– RN practice environment and job satisfaction

2.5 Selected Strategies and Tools for

Improving Safety

Following are some selected strategies and tools for improv-

ing safety in health care organizations.

2.5.1 Leadership Strategies

Successful improvement initiatives require leadership sup-

port; successful transformation of organizational culture

requires total leadership engagement. Study after study

shows leadership commitment to be the strongest dimension

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

of culture/climate, particularly commitment that is demon-

strated through deeds rather than words.

59–61

As noted in

Chapter 1, there is increasing consensus that meeting the

safety challenges facing health care will require a transforma-

tion in organizations and that leaders from all stakeholders

carry the responsibility of making it happen.

Leadership

responsibilities and the need for transforming existing man-

agement structures have been examined by an array of pub-

lic and private entities working to promote enhanced safety

and quality of care. For example, the IHI’s white paper

Leadership Guide to Patient Safety

describes the role of lead-

ership “to establish the value system in the organization; set

strategic goals for activities to be undertaken; align efforts

within the organization to achieve those goals; provide

resources for the creation, spread, and sustainability of effec-

tive systems; remove obstacles to improvements for clini-

cians and staff; and require adherence to known practices

that will promote patient safety.”

Adopting the principles

used in high reliability organizations described in Chapter 1

is thought to hold great promise for improving health care

safety and quality.

64,41

Leadership across all levels in health

care, from providers to evaluators, has a critical role to play

in promoting safety. Leaders drive organizational values,

which in turn drive behaviors that then drive performance.

What strategies and tools will assist a leader to achieve suc-

cess? Here are a few suggestions.

2.5.1.1 Tell Real Stories

Storytelling involves sharing real-life examples of safety inci-

dents to demonstrate important health and/or safety con-

cerns, risks, or outcomes impacting patients and health care

workers. Raising the awareness of all levels of leadership

from the board to frontline managers regarding the risks,

events, and opportunities for improvement in employee and

patient safety is imperative. In Chapter 1, storytelling was

used as a powerful tool by St. Vincent’s to build will (gain

support) within the organization. (See Chapter 1, Case

Study, “Building a High Reliability Culture for Patients and

Health Care Workers, St. Vincent’s Medical Center,

Bridgeport, Connecticut,” page 15.) Leaders and employees

can use this tool to increase awareness across the organiza-

tion and to promote an understanding of the safety risks

common to patients and workers.

2.5.1.2 Conduct Leadership Rounds

Leadership rounds engage senior organizational leadership

in making “rounds” to interact with frontline staff and

patients. For example, the IHI has a tool called Patient

Safety Leadership WalkRounds™ that enhances leadership

recognition and understanding of issues that affect direct

care staff.

This can be a vehicle to communicate organiza-

tional values and vision. When leaders go to the units and

“round” across shifts, staff do not have to leave the patient

care area to attend meetings. Identification of safety risks,

implementation of policies, and performance of procedures

can be discussed right where people work. In addition, this

method makes leaders visible and accessible, two tech-

niques used by successful managers. Communication

should be open and nonjudgmental. An example of apply-

ing this practice in the home care setting is described in

Case Study 2-2.

At Duke University Health Systems (DUHS), establishing

and maintaining a culture of safety is a primary strategic ini-

tiative across all system entities. In 2004 DUHS established

the Office of Patient Safety with a mission to educate leader-

ship and staff on implementing new systemwide safety stan-

dards and communication processes*. A comprehensive

education and training program in safety culture was devel-

oped and provided to all organizational leaders, managers,

supervisors, and staff. Safety leaders were named in each

DUHS entity, and a process was created for senior leaders to

interface with frontline staff for the purpose of sharing infor-

mation and ideas about patient safety. Based on work by

Allan Frankel, MD, the director of patient safety for Partners

HealthCare System in Boston, this informal exchange of

information informs leaders of staff concerns relating to

patient safety and promotes staff awareness of leadership’s

commitment to patient and staff safety.* In the hospital set-

ting this resulted in the creation of “Patient Safety

Leadership WalkRounds

”. Senior leadership at Duke

HomeCare & Hospice (DHCH) made a commitment to the

WalkRounds

concept and in 2006 implemented Director

Safety Rounds modeled after the inpatient process.

Structuring a Safety Rounds Program for the

Nonacute Care Setting

The objective of the DHCH safety rounds is to strengthen

the safety culture across all programs and departments by

CASE STUDY 2-2:

UKE HOME CARE: FOCUSING ON

SAFETY IN HOME CARE—THE DIRECTOR

SAFETY ROUNDS PROGRAM

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

improving communication and teamwork at all levels of the

organization. The senior leadership team is composed of the

executive director, medical director, and all program/depart-

ment directors. Examples of other participating directors

include the directors of hospice, home health, infusion,

accreditation and compliance, human resources, informa-

tion technology, finance, and development.*

To become familiar with the safety rounds concept,

DHCH leaders observed the WalkRounds

at DUHS

and then began a process of adapting/adopting rounds for

the nonacute care environment. The most significant dif-

ference involved identifying the programs and entities to

be visited and operationalizing rounds outside the hospital

setting. Programs and locations selected for rounds

beyond home care and hospice home patients (adult and

pediatric) are hospice skilled nursing and assisted living

facilities, DHCH pharmacy, DHCH distribution center

(supply storage and preparation for home delivery), and

office-based support staff (for example, information tech-

nology, referral and administrative staff, finance, human

resources, and so on).*

Key elements of the method developed for safety rounds are

as follows:

• Rounds are conducted throughout the year.

• All selected programs and locations are visited.

• Seven senior leaders each conduct a monthly safety

round in a selected program/location for three consecu-

tive months.

• Leaders use a script of questions to open dialogue with

staff (five questions) and patients/families (four ques-

tions) and to focus on identified themes (see Case Study

Table 2-1, page 50)

• Leaders respond to issues raised during rounds within

four weeks and provide feedback directly to staff.

• Safety rounds activities are reported and reviewed at sev-

eral levels including an all-agency staff meeting (quar-

terly), the agency’s Quality and Safety Core committee

(monthly), and the DUHS board of directors.

Spreading the Word and Improving Safety

Communication is the cornerstone of a successful safety

rounds program. For several months prior to initiation it

was featured in “THE LINK,” an internal agency newslet-

ter, followed by a formal introduction at an all-staff meet-

ing. The importance of open and honest discussions is

stressed and confidentiality is assured. Additional input is

obtained in monthly departmental meetings that are opened

by soliciting safety suggestions and concerns from staff. At

each quarterly all-staff meeting, a “safety story” is shared

that demonstrates how team members, patients, and/or care-

givers worked together to improve safety. A safety story

shared at a recent staff meeting described a medication

administration error discovered during a patient admission

procedure (see Case Study Sidebar 2-1, above).

The Safety Rounds Program has resulted in an increased

awareness of what safety issues concern staff most. For

example, reported concerns for personal and environmental

safety led to the development of a special proactive risk-

assessment team to address issues faced by agency staff con-

ducting home visits. A multiphase intervention began with a

staff survey inquiring what safety risks staff perceive. Survey

results were combined with staff interview data to identify

and prioritize safety risks, and to design improvement strate-

gies, which included a personal safety training program.

Another tool used to reinforce safety messages is the key

card. These laminated cards are carried on a ring and pro-

Case Study Sidebar 2-1:

Medication Reconciliation

(Duke Home Health)

Safety check protects Duke Home Health patient

from harm associated with inadvertent overdose.

As part of the admission process, a physical therapist

conducting a medication reconciliation in accordance

with the Duke Home Health medication reconciliation

policy discovered a discrepancy between the prescribed

dose of an anticoagulant medication and the dosage on

a box of prefilled syringes in the home. After reviewing

the doctor’s discharge instructions and speaking with the

patient, the therapist realized that the patient had been

taking more than twice the prescribed amount for the

previous five days. Further investigation revealed that

the pharmacy providing the medication had attached

written directions to the bag to take only the prescribed

amount but no further instructions on how to administer

the proper dosage. The patient had overlooked the

handwritten note and taken what he assumed was the

correct dosage. As a result of identifying the miscommu-

nication, a new pharmacy safety procedure was put in

place to verbally alert each patient when a dose requires

adjustment in administration. By carefully administering

the medication reconciliation procedure, the therapist

was able to correct the patient’s dosage before he expe-

rienced any adverse effects from the medication.

vide important reminders (for example, hand hygiene, how

to report a sharps injury, infection surveillance), telephone

numbers (emergency contact), nursing protocols (nursing

bag technique, how to access policies and procedures elec-

tronically), and clinical aides (pain scales, look alike/sound

alike medications).

Five Years and Going Strong

The Safety Rounds Program has been used successfully at

DHCH for more than five years. Benefits have included

enhanced communication across all levels of the agency and

a commitment to safety as an organizational priority. Staff

completing the annual Work Culture Survey gives high

marks to leadership for their support of the safety culture.

Also, it is significant to note that there have been no acts of

violence or other safety events involving staff in recent years.

Designing and implementing leadership safety rounds

required identifying strategies to overcome challenges posed

by diverse geographic service areas, multiple programs and

locations, and a mobile work force. As part of the DUHS

strategic safety initiative, this program has successfully estab-

lished a proactive approach to recognizing potential safety

risks and intervening before an error or injury harms a

patient or home care staff.

Source

* Mullin L. Keeping safety a priority in home care and hospice:

One agency’s journey. Home Healthcare Nurse. 2010

Feb;28(2):63–70. PubMed PMID: 20147799.

2.5.2 Management Strategies to Support

Staff Engagement in Improving Patient and

Worker Safety

Achieving improved safety for patients and workers begins

with organizational culture but is executed in job per-

formance. Every employee from support staff (housekeep-

ing) to direct care staff (nurses, therapists, physicians) has

some aspect of job performance that potentially affects

their own and patient safety. By providing positive feed-

back, employers can further safety. When adverse events

occur, or even near misses, strategies to support staff

recovery should be employed to hasten staff return to

maximum professional function. Finally, employees at all

levels are uniquely positioned to identify opportunities for

improvement and participate in development and imple-

mentation of solutions. As described by Berwick,

improvements in quality and safety occur most effectively

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Case Study Table 2-1:

Duke HomeCare & Hospice:

Focusing on Safety in

Home Care—

Safety Rounds Questions

The Director: Safety Rounds Program

Program/Area: ________________________________

Date of Safety Round: __________________________

Participants: __________________________________

____________________________________________

Introduce the Safety Rounds Team and Staff

Member:

Purpose: Share information and learn about real or

potential safety concerns. Assure staff that this is not a

test or an evaluation; encourage them to speak freely

and openly without fear of retaliation.

Questions to be asked of each staff member during

each safety round:

1. Tell me about the concerns you have related to

patient safety. How about your personal safety? Are

there any other safety concerns?

2. What is the next thing that could harm this patient in

particular, or any of our patients?

3. What specific intervention from leadership would

make the work you do safer for patients?

4. Are there any processes, policies, or Joint

Commission National Patient Safety Goals that are

not clear to you?

5. What aspects of the environment are likely to lead to

the next patient harm?

Questions to be asked of patients/caregivers during

each safety round:

1. Do you have any safety concerns or questions about

your care?

2. Do you know what to do in an emergency and how to

3. Do you have any suggestions to help us improve your

safety or the safety of others?

4. If the patient is using oxygen determine:

• If patient has been educated on oxygen safety in

the home

• If smoke alarms are present and in working order

• If there is a fire escape plan for the patient

Source: Mullin L. Keeping safety a priority in home care and

hospice. One agency’s journey. Home Healthcare Nurse.

2010:28(2);63–70. Used with permission.

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

when management entrusts and empowers staff to

improve processes; in turn, staff trust that management

supports their well-being and genuine desire to improve.

2.5.2.1 Provide Training, Time, and Resources

Though leadership ultimately determines resources, it is

managers who determine staff time and requirements for

training as well as implement the training. Managers

directly influence staff perception of the organization’s cul-

ture related to safety, learning, staff growth and develop-

ment, and teamwork. It is the manager’s responsibility to

operationalize the organization’s core values and provide

training and growth opportunities. The manager also needs

to allow sufficient time and resources for staff engagement

in safety improvement teams and initiatives.

2.5.2.2 Recognize or Reward All Efforts

Providing incentives and recognition for efforts to achieve

safety improvements are powerful tools that can reinforce

activities integrating patient and worker safety. Some

rewards will be inherent in the improved outcomes for

patients and workers. For example, interventions taken

within an organization to reduce the incidence of violence

have an inherent reward of making workers and other

patients feel safer and valued. In the case study on reducing

violence included in Chapter 3 (“Reducing assaults against

patients and staff in a behavioral health unit,” page 104),

the units were rewarded for maintaining defined periods

without a reported incident, thereby actively engaging both

staff and patients in the process. Frontline managers are

important facilitators in providing direct recognition, while

the organization can celebrate unit- and system-level safety

improvements for both patients and workers. Some organi-

zations may provide financial incentives based on the

achievement of performance goals as part of compensation

packages.

2.5.2.3 Utilize Frontline Safety Coaches, Champions, and

Unit Peer Leaders

In the Veterans Health Administration (VHA), they are

known as unit peer leaders; in other organizations they may

be called coaches or champions. Regardless of the titles

assigned, employees can be supported in keeping a focus on

safety by fellow frontline employees who have volunteered to

serve as safety leaders. These colleagues reinforce the organi-

zation’s safety culture as well as gather valuable first-hand

feedback on issues. They are a visible reminder of the organi-

zation’s commitment to worker and patient safety who can

provide on-site training and champion safety initiatives.

2.5.2.4 Analyze Feedback and Findings from Patient and

Worker Satisfaction Surveys to Identify Opportunities for

Improvement

It is critical to assess employee perception of organizational

values and safety climate in order to achieve system goals.

Employee satisfaction can reflect the health of the workplace

environment, which in turn affects employee well-being and

patient care. Patients and families should also be encouraged

to actively participate in efforts to improve safety, when pos-

sible, through the use of educational tools. Measuring

patient satisfaction and soliciting feedback also provides a

source of information on their perceptions of the quality of

care. For example, it has been found that lower patient satis-

faction scores may be present with higher incidence of staff

burnout.

Most health care organizations have established

methods for assessing patient and staff satisfaction. Surveys

may be conducted by external companies using standardized

tools or internally with customized instruments. These sur-

veys can provide a valuable source for identifying quality

improvement opportunities.

2.5.3 Tools to Enhance Communication

Communication is a critical factor in safety; the lack of

communication is often noted as a contributing factor in

adverse events. For example, communication failure was

identified as one of the top contributing root causes in sen-

tinel events reported to The Joint Commission from 2004

through third quarter 2011.

Faulty communication is

widespread in the health care setting, and it presents risks

for the safety of caregivers and patients alike.

Conversely,

open communication that promotes discovery of safety risks

by not hiding potential and actual system failures is a hall-

mark of high reliability organizations. Multiple communica-

tion strategies have been developed across other high risk

industries, such as space shuttle mission control, nuclear

power, and railroad dispatching. These provide a rich source

of tools for research and adaptation in the health care set-

ting. A few communication techniques are briefly described

here.

2.5.3.1 Daily Huddles

Daily huddles are briefings to review concerns, safety

events, near misses, and any safety-related issues that have

occurred across the entire organization during the previ-

ous 24 hours. Leadership huddles are attended by all

members and all levels of leadership to review events that

have been identified organizationwide (see Case Study

1-1, page 15). Unit-based huddles are briefings to review

safety events and concerns raised at the unit level that

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

consequently may be elevated to leadership or shared at

the organizational briefing as appropriate. Frontline staff

and managers should participate.

2.5.3.2 Phrase to Signal Concern and Demand Attention

One example of a communication technique to empower

staff to speak up when they see a potential safety issue is the

use of the acronym CUS—Concerned, Uncomfortable, and

Safety issue. As further described in the Pathways for Patient

Safety

document (listed in Resources 2-2, pages 57–60),

CUS is shorthand for a three-step process that assists people

in stopping the activity when they sense or discover a safety

breach. To be most effective, all members of the team

should be familiar with this technique and understand the

implications when a fellow team member says:

•I am Concerned.

•I am Uncomfortable.

• This is a Safety issue.

2.5.3.3 Teach Back or Repeat Back

Teach back is usually used in health care worker-patient

communication. The patient is asked to repeat back or

“teach back” the information provided to confirm accurate

understanding of material. However, health care workers are

encouraged to practice teach back or repeat back with their

colleagues as well as their patients.

These are considered

“closed loop” communication strategies (see Resources 2-2,

the Canadian Patient Safety Institute section).

2.5.3.4 Situation-Background-Assessment-

Recommendation (SBAR) Communication and SHARE

SBAR provides a standardized format for communication by

applying a framework for organizing information. It is an

easy-to-use format for structuring any communication

among heath care workers, but it is especially relevant when

exchanging clinical data between clinicians. The elements

include the following:

S = Situation (a concise statement of the problem)

B = Background (pertinent and brief information related

to the situation)

A = Assessment (analysis and considerations of

options—what you found/think)

R = Recommendation (action requested/recom-

mended—what you want)

When trained in the use of SBAR, staff can standardize

information transfer and minimize incomplete or unclear

communications. A toolkit and additional information on

this technique can be found at the IHI website.

Recently, The Joint Commission Center for Transforming

Healthcare released a tool for enhancing communication

during hand-offs. The acronym SHARE stands for the

following:

• Standardize critical content, which includes providing

details of the patient’s history to the receiver, emphasiz-

ing key information about the patient when speaking

with the receiver, and synthesizing patient information

from separate sources before passing it on to the receiver.

• Hardwire within your system, which includes develop-

ing standardized forms, tools, and methods, such as

checklists, identifying new and existing technologies to

assist in making the hand-off successful, and stating

expectations about how to conduct a successful hand-off.

• Allow opportunity to ask questions, which includes

using critical thinking skills when discussing a patient’s

case as well as sharing and receiving information as an

interdisciplinary team (for example, a pit crew).

Receivers should expect to receive all key information

about the patient from the sender, receivers should scru-

tinize and question the data, and the receivers and

senders should exchange contact information in the

event there are any additional questions.

• Reinforce quality and measurement, which includes

demonstrating leadership commitment to successful

hand-offs such as holding staff accountable, monitoring

compliance with use of standardized forms, and using

data to determine a systematic approach for improve-

ment.

• Educate and coach, which includes organizations teach-

ing staff what constitutes a successful hand-off, standard-

izing training on how to conduct a hand-off, providing

real-time performance feedback to staff, and making suc-

cessful hand-offs an organizational priority.

The Hand-off Communication Targeted Solution Tool

was created to measure the effectiveness of hand-offs within

an organization or to another facility and provide proven

solutions to improve performance. More information on

SHARE and access to the tool is available at

http://www.centerfortransforminghealthcare.org/projects

/detail.aspx?Project=171.

2.5.4 Tools for Risk or Hazard identification

and Adverse Event or Incident Analysis

As discussed previously in Chapter 1, high reliability organi-

zations have successfully created open and non-punitive

reporting systems of safety hazards, potential adverse events

(near misses), and actual adverse events. Traditional reporting

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

and surveillance systems, such as those described on page 45,

should be supplemented with real-time reporting strategies to

further combined analysis of patient and worker safety data.

In fact, recent research has shown that traditional paper-

based reporting systems capture neither near miss events nor

a significant number of actual adverse events.

72–74

Ultimately,

the true value of data lies in analysis and intervention as

depicted in the stages of the feedback loop (see Figure 2-5,

page 46). Analyzing events and data provides the high relia-

bility organization with rich learning opportunities, an

organization-specific risk profile, and direction for risk miti-

gation and quality improvement activities.

There are many established tools and strategies for risk and

hazard assessment and adverse event/incident analysis. The

following section introduces a few of the strategies.

2.5.4.1 Failure Modes and Effects Analysis (FMEA)

FMEA is defined by the IHI as “a systematic, proactive

method for evaluating a process to identify where and how it

might fail, and to assess the relative impact of different failures

in order to identify the parts of the process that are most in

need of change.”

The goal of an FMEA is to prevent errors

by attempting to identify all the ways the process could fail,

estimating the probability and consequences of each failure,

then taking action to prevent those from occurring.

2.5.4.2 Fault Tree Analysis

Fault tree analysis is a logical “top down” method of struc-

turing events and failures leading to a hazard. According to

OSHA, a fault tree analysis is a quantitative or qualitative

assessment of all the undesirable outcomes which could

result from a specific initiating event. It begins with a

graphic representation of all possible sequences of events

that could result in an incident. The resulting diagram looks

like a tree with many roots—each root depicts the sequen-

tial events (failures) for different independent paths to the

top event. Probabilities (using failure rate data) are assigned

to each event and then used to calculate the probability of

occurrence of the undesired event. It can also be used to

identify critical flaws (single point failures) that, by them-

selves, can directly set off an uncontrollable sequence of

events leading to an undesired outcome. This technique is

particularly useful in evaluating the effect of alternative

actions on reducing the probability of occurrence of the

undesired event.

(http://www.osha.gov/SLTC/etools/safety

health/mod4_tools_methodologies.html). Hyman

provides

an example of fault tree analysis applied to harm-related

clinical alarm failures.

2.5.4.3 Tracer Methodology for Safety Events

Tracer methodology, useful for analyzing systems and

processes for providing care, treatment, and services, can

also highlight performance issues within and among those

systems. The following three types of tracers can be con-

ducted: individual (follows the actual experience of an indi-

vidual), system based (follows a process or system across the

entire organization), and program specific (analyzes unique

characteristics and relevant issues of a specific type of organ-

ization.)

Practicing the use of this methodology by con-

ducting mock tracers will develop skills and enhance

understanding of the different types. A mock tracer work-

book, Environment of Care Tracer Workbook, is available that

provides guidance in conducting mock tracers.

2.5.4.4 Root Cause Analysis (RCA)

RCA is a process for identifying the basic or causal factor(s)

underlying variation in performance, including the occur-

rence or possible occurrence of a sentinel event.

RCA is

now widely used in health care as a tool to analyze errors. It

is an intensive form of assessment to determine what factors

cause, or explain, an event. The Agency for Healthcare

Research and Quality (AHRQ) recommends that RCAs fol-

low a prespecified protocol that begins with data collection

and reconstruction of the event through record review and

participant interviews. A multidisciplinary team should then

analyze the sequence of events leading to the error, with the

goals of identifying how (through the identification of active

errors) the event occurred and why (through systematic iden-

tification and analysis of latent errors) the event occurred.

Consideration of contributing factors should include cate-

gories such as institutional/regulatory, organization/manage-

ment, work environment, team environment, staffing,

task-related, and patient characteristics (when appropriate).

The Joint Commission requires that health care organiza-

tions complete an RCA in response to a sentinel event

(which is “an unexpected occurrence involving death or seri-

ous physical or psychological injury, or the risk thereof”).

The analysis is a process for identifying the factors that

underlie variation in performance, including the occurrence

or possible occurrence of a sentinel event. An RCA focuses

primarily on systems and processes, not on individual per-

formance. It progresses from special causes in clinical

processes to common causes in organizational processes and

systems and identifies potential improvements in these

processes or systems that would tend to decrease the likeli-

hood of such events in the future. The product of the RCA

is an action plan that identifies the strategies to reduce the

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

risk of similar events occurring. The plan addresses responsi-

bility for implementation, oversight, pilot testing as appro-

priate, time lines, and an approach for measuring the

effectiveness of the actions.

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Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

Resources 2-2: General Resources on Leadership and Work Environment

Title and Website Description

Agency for Healthcare Research and Quality (AHRQ)

TeamSTEPPS

: National Implementation

A teamwork system designed for health care professionals

that provides an evidence-based system to improve commu-

nication and teamwork skills.

Available at: http://teamstepps.ahrq.gov/about-2cl_3.htm

The system promotes the development of “highly effective

medical teams that optimize the use of information, people,

and resources to achieve the best clinical outcomes for

patients.” Complete program materials are available online

and in print format, including an instructor guide and compre-

hensive multimedia toolkit that contains:

• Fundamentals modules in text and presentation format

• A pocket guide that corresponds with the essentials version

of the course

• Video vignettes to illustrate key concepts

• Workshop materials, including a supporting CD and DVD,

on change management, coaching, and implementation.

Report

Becoming a High Reliability Organization: Operational Advice

for Hospital Leaders

Hines S, Luna, K, Lofthus J, et al. Becoming a High Reliability

Organization: Operational Advice for Hospital Leaders.

(Prepared by the Lewin Group under Contract No. 290-04-

0011.) AHRQ Publication No. 08-0022. Rockville (MD):

Agency for Healthcare Research and Quality. April 2008.

http://www.ahrq.gov/qual/hroadvice/hroadvice.pdf

This document shows how hospital leaders have taken the

five basic concepts of high reliability—sensitivity to opera-

tions, reluctance to simplify, preoccupation with failure, defer-

ence to expertise, and resilience—and used them to develop

and implement initiatives that are key to enhanced reliability.

The document shows how the concepts have been used to

change and respond to the external and internal environment;

plan and implement improvement initiatives; adjust how staff

members do their work; implement improvement initiatives

across a range of service types and clinical areas; and

spread improvements to other units and facilities.

AORN (Association of periOperative Registered Nurses), Inc.

Journal Article

Workplace Safety Equals Patient Safety

Spratt D, Cowles CE Jr, Berguer R, Dennis V, Waters TR,

Rodriguez M, Spry C, Groah L. Workplace safety equals

patient safety. AORN J. 2012 Sep;96(3):235-44. PubMed

PMID: 22935253.

http://www.sciencedirect.com/science/article/pii

/S0001209212007181

This article discusses a variety of topics related to workplace

safety, including fire safety, sharps safety, safe patient han-

dling, and smoke in the OR environment. The authors have

also solicited general discussions on workplace safety in the

OR and the sterile processing department, as well as work-

place safety issues from AORN’s perspective. The references

include links to several toolkits and other resources available

from AORN.

Canadian Patient Safety Institute

White Paper

Teamwork and Communication Working Group. Improving

patient safety with effective teamwork and communication:

Literature review, needs assessment, evaluation of training

tools and expert consultations. Edmonton (AB): Canadian

Patient Safety Institute; 2011.

http://www.patientsafetyinstitute.ca/English/toolsResources

/teamworkCommunication/Documents/Canadian%20Frame

work%20for%20Teamwork%20and%20Communications.pdf

This document summarizes the literature on effective team-

work and communication strategies. As described by the

authors, it provides a framework for organizations to under-

stand and convey to their teams the importance and impact of

teamwork and communication in healthcare, and to select

appropriate training tools to improve this.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Resources 2-2: General Resources on Leadership and Work Environment

(continued)

Title and Website Description

Centers for Disease Control and Prevention (CDC)

National Healthy Worksite Program

http://www.cdc.gov/nationalhealthyworksite/about/index.html

Webinar series

http://www.cdc.gov/nationalhealthyworksite/webinar

/registration.html

The National Healthy Worksite Program is designed to assist

employers in implementing science and practice-based pre-

vention and wellness strategies that will lead to specific, mea-

sureable health outcomes to reduce chronic disease rates.

The National Healthy Worksite Program seeks to promote

good health through prevention, reduce chronic illness and

disability, and improve productivity outcomes that contribute

to employers’ competitiveness.

Department of Veterans Affairs, Veterans Health Administration (VHA)

Kapinos KA, Fitzgerald P, Greer N, Rutks I, Wilt TJ. The

Effect of Working Conditions on Patient Care: A Systematic

Review. VA-ESP Project #09-009; 2012.

The Effect of Working Conditions on Patient Care (intranet

only) 01-2012

http://www.hsrd.research.va.gov/publications/esp/reports.cfm

This report is based on research conducted by the Evidence-

based Synthesis Program (ESP) Center located at the

Minneapolis VA Medical Center, Minneapolis, MN, funded by

the Department of Veterans Affairs, VHA, Office of Research

and Development, Health Services Research and

Development. The purpose of this report was to systemati-

cally review the evidence on the role of primary care

providers’ workplace conditions in influencing patient out-

comes. The researchers focused on patient satisfaction,

safety, and quality of care for patient outcomes.

European Agency for Safety and Health at Work

Occupational health and safety risks in the healthcare sector

— Guide to prevention and good practice

http://osha.europa.eu/en/legislation/guidelines/sector

_specific/occupational-health-and-safety-risks-in-the

-healthcare-sector-guide-to-prevention-and-good-practice

The content is divided as follows:

1. Prevention and health promotion as a management task

2. How to carry out a risk assessment

3. Biological risks

4. Musculoskeletal risks

5. Psychosocial risks

6. Chemical risks

The focus of this guideline is to present up-to-date technical

and scientific knowledge regarding the prevention of the most

significant risks in health care (especially biological, muscu-

loskeletal, psychosocial, and chemical risks), and to support

the implementation of the relevant European Union directives.

Practical instruments to support employers in identifying the

risks for the safety and health of their employees, and to

guide the implementation of preventive measures in their

health care facilities are outlined and clarified on 284 pages.

The manuscript was completed in December 2010.

Health Research and Educational Trust

White Paper

Pathways for Patient Safety

—Module One: Working as a

Team

Health Research & Educational Trust; Institute for Safe

Medication Practices; Medical Group Management Association

Center for Research; ISMP, 2008. Supported by a grant from

The Commonwealth Fund.

http://www.hret.org/quality/projects/resources/working_as

_a_team.pdf

This document, the first of a three-module set, contains infor-

mation, strategies, and tools designed to improve teamwork

and communication.

Includes information about CUS model and TeamSTEPPS.

Chapter 2: Management Principles, Strategies, and Tools That Advance Patient and Worker Safety and Contribute to High Reliability

Resources 2-2: General Resources on Leadership and Work Environment

(continued)

Title and Website Description

Institute for Healthcare Improvement (IHI)

White Paper

Leadership Guide to Patient Safety

http://www.ihi.org/knowledge/Pages/IHIWhitePapers/

LeadershipGuidetoPatientSafetyWhitePaper.aspx

This paper presents eight steps that are recommended for

leaders to follow to achieve patient safety and high reliability

in their organizations. Each step and its component parts are

described in detail in the sections that follow, and resources

for more information are provided where available.

National Institute for Occupational Safety and Health (NIOSH)

Website across numerous topics

http://www2a.cdc.gov/nioshtic-2/

Workplace Safety & Health Topics: HEALTHCARE

WORKERS

Search NIOSHTIC-2, a bibliographic database of occupational

safety and health publications, documents, grant reports, and

journal articles supported in whole or in part by NIOSH.

Subheadings with content on this site include:

• general resources

• biological hazards and controls

• chemical hazards and controls

• physical hazards and controls

• work organization

• reproductive health

• dentistry

• emergency preparedness and response

• surveillance and statistics

• related sites

Publication

The Changing Organization of Work and the Safety and

Health of Working People

http://www.cdc.gov/niosh/docs/2002-116/

This publication discusses sweeping changes in the organiza-

tion of work that have been influenced by major economic,

technological, legal, political, and other forces.

Home Healthcare Worker “Fast Facts” Sheets

http://www.cdc.gov/niosh/pubs/fact_date_desc_nopub

numbers.html

a) NIOSH Hazard Review: Occupational Hazards in Home

Healthcare

Department of Health and Human Services (DHHS) (NIOSH)

Publication No. 2010-125 (January 2010)

b) NIOSH Fast Facts: Home Healthcare Workers – How to

Prevent Needlestick and Sharps Injuries

DHHS (NIOSH) Publication No. 2012-123 (February 2012)

c) NIOSH Fast Facts: Home Healthcare Workers – How to

Prevent Driving-Related Injuries

DHHS (NIOSH) Publication No. 2012-122 (February 2012)

d) NIOSH Fast Facts: Home Healthcare Workers – How to

Prevent Exposure in Unsafe Conditions

DHHS (NIOSH) Publication No. 2012-121 (February 2012)

Continued on next page

a) This document describes occupational hazards in home

health care (e.g., muscuoloskeletal overexertion, violence,

needles, and bloodborne pathogens, etc.) and suggests pre-

ventive strategies for employers and workers.

b) This document presents examples of activities with poten-

tial for needlestick injuries and provides measures that

employers and employees can take to prevent needlestick

and sharps injuries in home healthcare settings.

c) This document describes measures employers and

employees can take to prevent car accidents when home

health care workers are driving from client to client.

d) This document describes measures employers and

employees can take to prevent exposure to unsanitary condi-

tions, temperature extremes, hostile animals, and other haz-

ards when working in the homes of their clients.

Continued on next page

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Resources 2-2: General Resources on Leadership and Work Environment

(continued)

Title and Website Description

National Institute for Occupational Safety and Health (NIOSH) [continued]

e) NIOSH Fast Facts: Home Healthcare Workers – How to

Prevent Musculoskeletal Disorders

DHHS (NIOSH) Publication No. 2012-120 (February 2012)

f) NIOSH Fast Facts: Home Healthcare Workers – How to

Prevent Latex Allergies

DHHS (NIOSH) Publication No. 2012-119 (February 2012)

g) NIOSH Fast Facts: Home Healthcare Workers – How to

Prevent Violence on the Job

DHHS (NIOSH) Publication No. 2012-118 (February 2012)

h) Risk Factors Associated with Patient Assaults of Home

Healthcare Workers

Rehabil Nurs 2010 Sep/Oct; 35(5):206-215

http://www.cdc.gov/niosh/programs/hcsa/pubs.html

e) This document describes measures employers and

employees can take to prevent work-related musculoskeletal

disorders associated with lifting and moving clients in home

health care settings.

f) This document describes the types of reactions that can

occur when using latex products and measures employers

and employees can take to prevent latex allergies in home

health care settings.

g) This document describes measures employers and

employees can take to prevent violence, ranging from verbal

abuse, to stalking or threats of assaults, to homicide in home

health care settings.

h) This study used surveys from 677 home health care aides

and nurses to explore factors associated with assaults by

patients. Among respondents, 4.6% reported one or more

patient assaults (being hit, kicked, pinched, shoved, or bitten)

during the past year.

The Joint Commission

White Paper

Health Care at the Crossroads: Guiding Principles for the

Development of the Hospital of the Future

http://www.jointcommission.org/assets/1/18/Hosptal

_Future.pdf

This white paper addresses broad issues relating to the provi-

sion of safe, high-quality health care and, indeed, the health

of the American people. The white paper represents the cul-

mination of a roundtable discussion. Proposed principles for

guiding future hospital development are summarized.

Specific Examples of

Activities and Interventions

to Improve Safety

s discussed in the preceding chapters, a high reliability organization incorpo-

rates safety as a core value and successfully integrates safety into the way it does

business. Although health care settings are varied and present both common and

unique safety issues, interventions to improve safety for patients often also

improve safety for workers. Very rarely do interventions targeting patient safety conflict with

safety goals for workers and vice versa.

In this chapter, several topics have been selected that demonstrate the synergy between health care worker and

patient safety. These topics are as follows:

• Musculoskeletal injuries resulting from patient handling and slips, trips, and falls

• Sharps injuries and infection transmission

• Hazardous drugs, chemicals, and radiation

• Violence in the health care setting

• Staffing, fatigue, and health care–induced emotional distress

Abundant literature and resources are available on these topics, reflecting their impact on patients or health care

workers. Therefore, this chapter is not intended to provide a comprehensive review of each topic but rather to

encourage discussion of the relationship between patient and worker safety in these areas and highlight the value of

coordinating safety efforts. Sample resources are included and for several topics, actual organizational practice exam-

ples that address both patient and worker safety are described.

– Chapter 3 –

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

3.1 Musculoskeletal Injuries and

Accidents

3.1.1 Safe Patient Handling

Few activities in health care link patient and worker safety

more directly than lifting, transferring, repositioning, and

ambulating patients. As part of the larger science of

ergonomics dealing with the intersection of physical work

requirements and the capacity of the worker, patient han-

dling is a high risk activity for work-related musculoskeletal

injuries (see Chapter 2, page 35). These injuries are often

grouped under the heading of musculoskeletal disorders

(MSDs). Back injuries represent a large percentage of

MSDs; however, injuries can also involve the neck, shoul-

ders, wrists, and knees.

1,2

Despite a significant body of evidence that manual patient

handling is not safe for patients or health care workers,

changing the practice has been difficult. While MSD

injuries have declined in most industries in recent years,

rates for nurses in the health care industry have not declined

during the same period.

Research on safe patient handling

techniques has demonstrated that injuries can be reduced

when manual handling is eliminated to the greatest extent

possible. Internationally, other countries have enacted legis-

lation and implemented policies to address risks involved in

patient handling. In 1992, the United Kingdom was the

first country to enact a national policy that applied mini-

mum ergonomic standards to reduce the injury rate associ-

ated with manual patient handling.

Risks are inherent in

moving and lifting patients and can originate as a result of

both workplace and human factors. The National Institute

for Occupational Safety and Health (NIOSH) has identified

risks within system elements across three health care settings

(Table 3-1, pages 63–64).

Most health care workers in the United States have been

taught the use of “proper” body mechanics and transfer

techniques, such as the hook-and-toss method, which have

been shown to be unsafe.

Other common practices include

manual patient lifting and use of back belts. A growing

body of evidence questions the effectiveness of these tech-

niques in reducing injuries and promoting safe patient han-

dling.

Proven effective techniques include the following:

• Selection of appropriate mechanical patient-handling

equipment and devices

1,4

• Sufficient training on proper operation of lifting

equipment

1,4

• Accurate completion of patient mobility assessment

matched to equipment and protocols

1-4

• Safe-lifting policies and procedures

1-4

• Specialized patient lift teams when available

1,4

According to 2009 data from the Bureau of Labor Statistics

(BLS), registered nurses, nursing assistants and orderlies,

and licensed practical nurses suffered the highest prevalence

and reported the most annual cases of work-related back

pain involving days away from work in the health care and

social assistance sector.

Emergency medical personnel are

also at risk. In fact, health care workers and patients are at

risk for injuries related to handling anywhere care is deliv-

ered, including hospitals, long term care facilities, outpatient

treatment centers, specialty care institutions, and home care.

3.1.1.1 Impact on Patients and Workers

Work-related MSDs such as back and shoulder injuries

experienced by nurses and patient care staff are among the

highest of any occupation. In addition to sudden onset

injuries, MSDs occur as a result of the cumulative effect of

long-term and repeated overexertion over the course of a

working lifetime.

Data collected in 2007 showed that nurs-

ing assistants, orderlies, and attendants experienced a rate of

MSDs seven times higher than the national MSD average

for all occupations.

Also, the nursing profession is typically

listed as one of the top 10 occupations with the highest

annual incidence rates for sprain and strain injuries.

Although the number of reported injuries is alarming, under-

reporting of injuries is also a significant issue. Reasons for

underreporting are varied but include the difficulty in linking

symptoms to specific work-related risk factors and resistance

to reporting injuries and/or filing for workers’ compensation.

MSDs result in significant costs, both personal and financial.

Back pain and injury lead some nurses to consider transfer-

ring jobs or even leaving the profession altogether.

In addi-

tion to the direct costs of injury treatment and workers’

compensation payments, there are indirect costs associated

with temporary or permanent personnel replacement.

Patients are also at risk of multiple injuries and adverse

events related to handling procedures. These include pain

and discomfort as well as anxiety connected with being

moved. Physical outcomes can include fractures from being

dropped during lifting activities, shoulder damage from

manual lifting/repositioning, and bruises and skin tears.

Transfer and lifting equipment use can also lead to injuries

when patient characteristics (for example, weight, functional

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

Table 3-1: Examples of NIOSH-Identified Risks for Musculoskeletal

Injuries in Health Care Settings

System

Element

Hospital Nursing Home Home Care

Environment 1. Patient transfer needs are

rarely considered in building

design and layout of critical

areas such as patient rooms,

surgery suites, emergency

room, etc.

2. Installation of ceiling lifts is

often structurally inadequate.

3. Room design limits use of

mechanical lifts, especially

access to patient bathroom.

4. Lack of storage for equipment.

5. Patient transport over carpet-

ing, poorly functioning wheels

on carts, and transfers from

carts to stationary imaging

tables.

1. Financial constraints on institu-

tion due to lower reimburse-

ment by federal/state agencies.

2. Old facilities with inadequate

structures for ceiling lifts or

storage for floor lifts.

3. Room layout often too confined

for equipment-related transfers.

4. Bathroom layout/size is inade-

quate for two caregivers and

equipment access.

1. Confined areas obstructed with

furniture, equipment, etc.

2. Inaccessible bathrooms.

Work

Organization

1. Staff turnover—challenge of

training new hires.

2. Long shifts, mandatory over-

time leading to mental and

physical exhaustion.

3. Perceived increase in time

required to use transfer equip-

ment leads to manual handling

of patients.

4. Lack of training and reinforce-

ment on use of equipment due

to competing demands.

5. Use of temporary/agency staff

without adequate training in

equipment use.

1. Lack of safe lifting policies

2. Shortage of skilled staff.

3. High turnover of management

and workers creates chal-

lenges in training all newly

hired caregivers.

4. Low wages with limited

benefits.

5. Limited time for training due to

competing demands.

6. Perception that it often takes

too much time to find and use

lifting equipment and reposi-

tioning devices.

1. Health care workers often work

alone without assistance.

2. Work schedules are over-

loaded with too many patients.

3. Higher acuity and increased

number of patients at home

due to shorter hospital stays.

4. Lack of control over work

planning.

Technology/

Equipment

1. Ceiling lifts are expensive to

install unless remodeling or

new construction.

2. Equipment mounted to hospital

structure requires construction

approval.

3. Slings are difficult to place on

patients—especially bariatric.

4. Time to locate and obtain

mechanical devices.

5. Difficult to provide sufficient

training to all staff who handle

patients.

1. Inadequate mechanical equip-

ment and devices to lift and

reposition residents.

2. Sufficient slings of adequate

size are often not available.

3. Slings can be lost or misplaced

when laundered.

4. In some cases, the mainte-

nance department does not

have a tagout procedure for

identifying broken equipment

and repair procedures for serv-

icing equipment and transfer-

ring devices.

1. Lack of mechanical lifting

devices.

2. Beds are generally not

adjustable.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Table 3-1: Examples of NIOSH-Identified Risks for Musculoskeletal

Injuries in Health Care Settings (continued)

System

Element

Hospital Nursing Home Home Care

Tasks 1. Patient transfers, lifting, and

repositioning.

2. Patient transport.

3. Care procedures require awk-

ward positions (for example,

feeding, wound care)

4. Rapid patient turnover and

condition change demand fre-

quent assessment and quick

adjustment by nursing staff.

5. Diagnostic and treatment pro-

cedures may require awkward

postures, patient handling, and

static high hand forces by staff

in radiology, imaging, occupa-

tional, and physical therapy.

1. Transferring residents from

very low beds to wheelchairs

requires extreme back flexion

and twisting, neck extension,

and high back and shoulder

2. Repositioning in bed requires

forceful, awkward postures.

3. Dressing, feeding, and per-

sonal care assistance requires

awkward postures.

4. Many residents suffer from

dementia and are easily con-

fused and agitated, particularly

during a transfer, resulting in

combative behavior.

1. Frequent lifting and reposition-

ing while bending, stooping,

twisting, and reaching over low

beds to assist with wound care,

bathing, etc.

2. Increasing size of patients

makes it difficult to obtain a

firm grip.

3. Postural instability of patients.

4. Combativeness of agitated or

confused patients.

5. Health care workers also per-

form physically demanding

housekeeping activities includ-

ing cleaning, cooking, laundry,

and shopping. In some cases

these types of tasks have been

found to represent an equal or

greater risk of injury to home

care workers than patient care

tasks.

Workers 1. Strength requirements of lifting

and moving patients often

exceed the lifting capacity of

health care workers.

2. Largely female workforce.

3. No time for training.

4. Perceived increase in time to

use equipment.

5. Perceptions and habits focus

on the patient, not on oneself.

6. Belief that manual lifting and

transfers “are part of the job.”

7. Taught in school in the use of

“good body mechanics”

and “safe lifting/transfer

techniques.”

1. Certified nursing assistants are

often female, unskilled, in their

first job, and speak English as

a second language.

2. Caregivers are exposed to

excessive psychological and

physical job demands.

1. Home health care workers are

aging and approximately 90%

female.

2. Often unaware of risks or

access to alternative methods

of handling clients.

Adapted from source: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for

Occupational Safety and Health [Internet]. State of the Sector | Healthcare and Social Assistance: Identification of Research Opportunities for

the Next Decade of NORA. DHHS (NIOSH) Publication Number 2009-139. Available from: http://www.cdc.gov/niosh/docs/2009-139.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

capability) are not properly matched to equipment capaci-

ties, equipment is not well maintained, or employees have

not been trained or are not proficient in its use.

3.1.1.2 Examples of Interventions

Evidence-based solutions that reduce injuries and increase

patient and worker safety have been identified.

8,9

While dif-

ferent care settings, caregivers, and patients require targeted

methods and application-specific solutions, some general

approaches have proven effective. Nelson and Baptiste

have

suggested the following three categories of control solutions:

engineering, administrative, and behavioral. Sidebar 3-1

shows examples of controls within each category. For more

information on the hierarchy of controls, see Chapter 2,

Section 2.2.

Regardless of the care setting, effective solutions will require

active participation of caregivers and patients to overcome

barriers to using new techniques and practices. Transfer and

lifting equipment may induce anxiety and will require time,

cooperation, and training for successful implementation.

However, attention to the issue of safe patient handling has

helped stimulate research, introduce new interventions, and

expand the evidence base for practice with the promise of

improved health and safety for patients and workers. Collins

et al.

identified benefits for residents, employers, and care-

givers gained from implementing a safe resident lifting pro-

gram in a nursing home (Table 3-2, page 66). Other health

care settings may realize similar benefits after implementing

a safe patient lifting program.

Many organizations are making safe patient handling a priority

for the benefit of patients and staff. Two examples of organiza-

tional approaches will be studied. One organization identified

a special-need patient population, while the other addressed

implementing a program across a large multihospital system.

Sidebar 3-1: Interventions to

Reduce Injuries and Increase

Patient and Worker Safety

• Engineering Controls: Modifications to the work

environment that create permanent changes to miti-

gate risk

– Room design, access, and layout

– Mechanical lifting devices such as ceiling-mounted

or mobile equipment

– Raised toilet seats, grab bars, and other assistive

devices

– Beds with adjustable height positions and other

adaptive features

• Administrative Controls: Policies, procedures, and

practices enacted by organizational management or

legislative action, as well as guidelines, recommenda-

tions, and position statements of professional associa-

tions and official agencies

– Safe-lifting policies. These policies are intended to

match transfer and repositioning techniques to the

physical and cognitive status of the patient and

require that proper engineering controls and infra-

structure (patient assessment tools, staff educa-

tion) be established.

– Ergonomic assessment protocols for patient care.

Standardized tools to determine patient character-

istics (for example, combativeness and ability to

bear weight, assist with transfers, and other mobil-

ity limitations) and match these to appropriate

equipment and procedures.

– Patient lift/transfer teams. Selected staff who have

received specialized training in the use of

mechanical equipment and assist with high risk

lifts/transfers. Creating a “lift team” does not

address patient handling tasks such as reposition-

ing, and it may be difficult to find qualified and will-

ing individuals. In addition, the demand across an

entire facility may exceed team resources.

• Behavioral Controls: Educational tools and training

to reduce risks to caregivers associated with patient

handling.

– Education and training in the proper use of patient

handling equipment coupled with proper body

mechanics.

– Deployment of safety leaders to serve as role

models, educators, and unit-based resources.

– Cultural change from expectation that manual lift-

ing is “part of the job” and perception of need to

place personal health and safety second to

patient/job requirements.

Adapted from source: Nelson A, Baptiste A. Evidence-based

practices for safe patient handling and movement. Online J

Issues Nurs [Internet]. 2004 Sep 30 [cited 2011 Oct 11];9(3

Suppl 3). Available from: http://www.nursingworld.org/Main

MenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Tableof

Contents/Volume92004/No3Sept04/EvidenceBasedPractices.aspx.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Table 3-2: Benefits of a Safe Patient-Resident Lifting Program

Benefits for Patients/Residents Benefits for Employers Benefits for Caregivers

Improved quality of care Reduced number and severity of staff

injuries

Reduced risk of injury

Improved patient/resident safety and

comfort

Improved patient/resident safety Improved job satisfaction

Improved patient/resident satisfaction Reduced workers’ compensation med-

ical and indemnity costs

Increased morale

Reduced risk of falls, being dropped,

friction, burns, dislocated shoulders

Reduced lost workdays Injured caregivers are less likely to be

reinjured

Reduced skin tears and bruises Reduced restricted workdays Pregnant caregivers can work longer

Reduced overtime and sick leave Staff can work to an older age

Improved recruitment and retention of

caregivers

More energy at the end of the work shift

Fewer resources required to replace

injured staff

Less pain and muscle fatigue on a daily

basis

Source: Collins JW, Nelson A, Sublet V; Department of Health and Human Services, Centers for Disease Control and Prevention, National

Institute for Occupational Safety and Health. Safe Lifting and Movement of Nursing Home Residents [Internet]. Cincinnati (OH): NIOSH-

Publications Dissemination; 2006 Feb [cited 2011 Oct 11]. Available from: http://www.cdc.gov/niosh/docs/2006-117/.

Resources 3-1: Safe Patient Handling

Title and Website Description

American Nurses Association (ANA)

Brochures and Toolkits

Patient Care Ergonomics Resource Guide: Safe Patient Handling

and Movement

http://nursingworld.org/MainMenuCategories/WorkplaceSafety/Safe

Patient

This site links the reader to information, brochures,

and toolkits from the ANA Nursing World on safe

patient handling.

ANA Handle with Care

Program

http://www.nursingworld.org/MainMenuCategories/Occupationaland

Environmental/occupationalhealth/handlewithcare.aspx

An industry-wide effort designed to prevent back and

other musculoskeletal injuries among the nation’s

nurses.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

Resources 3-1: Safe Patient Handling (continued)

Title and Website Description

Association of Occupational Health Professionals (AOHP)

Beyond Getting Started: A Resource Guide for Implementing a Safe

Patient Handling Program in the Acute Care Setting

http://www.aohp.org/About/documents/GSBeyond.pdf

This resource guide addresses patient handling with

the goal of providing the necessary tools for the

occupational health professional in health care to

implement a safe patient handling program.

Department of Veterans Affairs (VA), Veterans Health Administration (VHA)

Veterans Affairs Safe Patient Handling Program

http://www.visn8.va.gov/patientsafetycenter/safePtHandling

Develop and test innovations and decrease risk

related to patient handling and movement.

Department of Veterans Affairs

Safe Patient Handling and Movement

http://www.visn8.va.gov/visn8/patientsafetycenter/

There are multiple guides, toolkits, and algorithms for

safe patient handling and movement available for

downloading.

National Institute for Occupational Safety and Health (NIOSH)

Safe Patient Handling Index

http://www.cdc.gov/niosh/topics/safepatient/

Safe Lifting and Movement of Nursing Home Residents

Department of Health and Human Services (DHHS) (NIOSH)

Publication Number 2006-117 (February 2006)

http://www.cdc.gov/niosh/docs/2006-117/

This site provides safe patient handling resources

and links the reader to published research, practical

guidance, and conference information related to safe

patient handling.

This guide also provides a business case and is

intended for nursing home owners, administrators,

nurse managers, safety and health professionals, and

workers who are interested in establishing a safe res-

ident lifting program.

Curricular Materials

Safe Patient Handling Training for Schools of Nursing

DHHS, NIOSH, Veterans Health Administration (VHA), and the ANA

November 2009

http://www.cdc.gov/niosh/docs/2009-127/pdfs/2009-127.pdf

A curriculum designed to provide evidence-based

training on safe patient handling to instructors of nurs-

ing for use in nursing education programs as well as

for use by health care groups for retraining current

nurses and other health care workers. Provides a full

range of educational tools and links to Tool Kit for Safe

Patient Handling and Movement Training Program.

Report

Collins J, Silverstein B, and Stock L.

Chapter 11: Musculoskeletal Disorders and Ergonomic Issues

In: US Department of Health and Human Services, Centers for

Disease Control and Prevention, National Institute for Occupational

Safety and Health [Internet]. State of the Sector | Healthcare and

Social Assistance: Identification of Research Opportunities for the

Next Decade of NORA. DHHS (NIOSH) Publication Number 2009-

139. Available from: http://www.cdc.gov/niosh/docs/2009-139

This 236 page document, developed by the NORA

Healthcare and Social Assistance Sector Council,

addresses the "state of the sector", including magni-

tude and consequences of known and emerging

health and safety problems, critical research gaps,

and research needs that should be addressed over

the next decade of NORA. Chapter 11 discusses

musculoskeletal disorders and ergonomic issues.

Lancaster General Hospital

Lancaster, Pennsylvania

In 2007, Lancaster General became an OSHA Voluntary

Protection Program (VPP) site. This program recognizes

“employers and workers in the private industry and fed-

eral agencies who have implemented effective safety and

health management systems and maintain injury and ill-

ness rates below national BLS averages for their respective

industries. In VPP, management, labor, and OSHA work

cooperatively and proactively to prevent fatalities, injuries,

and illnesses through a system focused on: hazard preven-

tion and control; worksite analysis; training; and manage-

ment commitment and worker involvement.”* Dedicated

leadership commitment and an organizational focus on

safety for patients and employees led to further recogni-

tion as a star site within the VPP program. As safety

became integral to the work environment, new opportuni-

ties to improve worker and patient safety were identified.

Examples of programs that integrate patient and worker

safety at Lancaster General include a fall prevention pro-

gram and the Image Gently program

†

for patients as

well as electronically tracking total x-ray exposure for

employees.

One opportunity, the bariatric patient initiative, was identi-

fied when facility resources were insufficient to meet

requirements of care for an individual whose weight

exceeded existing capacity. By integrating the focus on

employee safety modeled in the VPP program with patient

safety goals, this initiative exemplifies the value of using a

combined approach to patient and worker safety.

Developing a Strategic Plan to Serve Bariatric

Patients

The vice president of operations became the project’s execu-

tive sponsor, and the Bariatric Steering Committee was

formed under the joint leadership of the director of nursing

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Resources 3-1: Safe Patient Handling (continued)

Title and Website Description

Occupational Safety and Health Administration (OSHA)

Website

OSHA – Voluntary Protection Program

http://osha.gov/dcsp/vpp/index.html

A voluntary program that recognizes successful appli-

cants who have implemented safety and health man-

agement systems and maintain injury and illness

rates below national BLS averages for their respec-

tive industries.

Washington State

Safe Patient Handling Program

http://washingtonsafepatienthandling.org/

Developed by the Safe Patient Handling Steering

Committee in Washington State to assist hospitals in

implementing a safe, cost-effective patient handling

program.

Work Injured Nurses’ Group (WING)

Website

WING USA

http://www.wingusa.org

Group that provides information and personal support

to nurses affected by injury or ill health through a

newsletter and dedicated advice line. Members can

get advice on rights, government benefits, and sup-

port from others who have “been there.” Membership

is free and also open to interested parties.

CASE STUDY 3-1: LANCASTER VOLUNTARY

PROTECTION PROGRAM: COMMITMENT

BARIATRIC PATIENT SAFETY

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

and the manager of employee and student health and safety.

The task force included diverse representation from depart-

ments such as materials management, transport, environ-

mental services, dietetics, nursing, pharmacy, and so on.

Using performance improvement methodology and VPP

approaches, the task force assessed the current resources (gap

analysis) to serve this population and conducted a patient

survey. To understand the current health care experiences of

bariatric patients, an online survey with a sample of resi-

dents living in the Lancaster General markets and service

areas was completed. To be eligible for participation, respon-

dents had to weigh 250 pounds or more. Objectives of the

survey were to:

• Identify obstacles or barriers in getting care; and

• Identify ways to improve the bariatric patient experience.

A total of 213 persons participated in the survey, the

results of which provided the patient’s perspective.

Additionally, a process improvement engineer was engaged

in a walkthrough of the entire facility to assess the poten-

tial safety risks posed for a bariatric patient and health

care staff during a hospitalization. The walk-through con-

sidered all the different ways a bariatric patient might

enter the system and all the departments that might be

accessed for care. As a result of the evaluation process,

barriers to care were documented as well as safety hazards

that staff might encounter while caring for these patients.

Priority areas were selected and workgroups were created

to address specific issues. For example, a subgroup exam-

ined current equipment and evaluated additional needs.

Finally, a facility-wide assessment was conducted to evalu-

ate existing structures (such as door widths), diagnostic

equipment (such as diagnostic tables/chairs), and fixtures

and mobility devices (for example, wall toilets and wheel

chairs).

Identifying Barriers to Implementing a Bariatric

Patient Care Program

Several obstacles were identified while planning for a

bariatric patient care program. One of the first obstacles

identified was the lack of consistently available patient

weight and body mass index (BMI) data to identify the

bariatric patient population. Another potential barrier was a

general lack of knowledge about, and cultural attitudes

toward, the bariatric population. Structural and functional

barriers involved building design and the cataloging, track-

ing, and storing of bariatric equipment. Finally, staff was

unfamiliar with the appropriate selection and use of new

equipment.

A Bariatric Patient Care Program to Protect

Patients and Health Care Workers

Following the organizational needs assessment and identifi-

cation of program barriers, the task force designed a com-

prehensive program to care for this population that

considers safety for patients and staff. First, an educational

curriculum was designed to provide information about cul-

tural attitudes and sensitivities in caring for the bariatric

patient. All patient care staff received this education. Patient

weight and BMI data were made available to facilitate

proper care planning. The electronic medical record alerts

staff to special patient needs and allows staff to select orders

when the individual’s BMI is greater than 35. For example,

a nutritional assessment should be completed, as experience

has shown that this population may actually be malnour-

ished in essential nutrients.

A mobilization assessment tool was created and incorporated

into the existing fall prevention assessment that is completed

every 24 hours. All nursing staff received training in the

completion of this assessment and the selection of equip-

ment and care processes to match mobility needs. Laundry

personnel were educated in caring for the slings used with

the new equipment. Special bariatric rooms were created

that have ceiling lifts capable of carrying up to 1,000

pounds, while other rooms have been equipped with ceiling

lifts with a 600-pound capacity. In addition, use of a patient

air-lift and transfer system was instituted. To assist staff with

proper equipment selection, an online resource and a

spreadsheet detailing lift devices and other equipment along

with their weight limits was created and provided to nursing

supervisors. A special storage area was designed and the

location of each piece of equipment was also provided to

facilitate quicker access. Visual clues included the use of red

blankets on the beds of patients requiring more supervision.

When admissions are planned in advance, a bariatric bundle

including a bed, commode, walker, and wheelchair as well

as a lift, if needed, is prepared and made available prior to

the patient’s arrival.

Other facility changes have addressed structural barriers.

Safety enhancements have been added to wall toilets and

diagnostic equipment chairs. Door widths and related con-

struction has been completed to accommodate bariatric

devices such as specialty wheel chairs. Finally, needs such as

specially sized patient gowns have been addressed. Taken

together, all components of the program have resulted in

heightened awareness of how to safely and comfortably meet

the care needs for the bariatric patient.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Improvement in employee injury data has been docu-

mented since program implementation. There has been a

30% decrease in OSHA recordable injuries associated

with lifting and assisting patients out of bed between

2007 and 2009 (program initiated in 2008). This trans-

lates into a potential cost savings of $21,000 per year

based on an average injury cost of $3,000.

Making Safety an Organizational Value

The bariatric program is a good example of the integrated

patient and worker safety planning used at Lancaster

General Hospital. Representatives from all departments,

patient safety, and a variety of job positions contribute to

committees supporting work site analysis and hazard

assessment. Focusing on safety is contagious and has

become a way of life within the organization. While safety

is serious business, making it visible and fun is also

important to promoting success. Baxter, a safety mascot,

attends organizational events and randomly greets

employees upon arrival or exiting the elevator and at new

employee orientation (see Case Study Figure 3-1). The

safety logo is visible on all initiatives (for example, flu

shot campaign, hand-washing reminders, driving slowly in

the parking lot) and on pins given to staff. For Lancaster

General Hospital, connecting patient and worker safety

makes sense; employee safety leads to patient safety and

vice versa.

Case Study References

* Occupational Safety and Health Administration [Internet].

Voluntary Protection Program (VPP); [cited 2011 Sep 26].

Available from: http://www.osha.gov/dcsp/vpp/index.html.

† Society of Pediatric Radiology [Internet]. Image Gently

Campaign; c2011 [cited 2012 Jan 31]. Available from:

http://www.imagegently.org.

Case Study Figure 3-1: Baxter (Safety Mascot) and Baxter with Staff at

Voluntary Protection Program Survey (Lancaster General Hospital)

Baxter and Lancaster Staff at VPP Survey

Source: Lancaster General Hospital. Lancaster, PA. Used with permission.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

Intermountain Healthcare

Salt Lake City, UT

A program protecting staff and patients from injury related

to transfers, lifting, and falls is a key strategy for safe, high-

quality care at Intermountain Healthcare (IH). This non-

profit system consists of 22 hospitals and more than 100

clinics in Utah and Idaho. Leadership at Intermountain

launched a team in 2006 to evaluate transfer and lifting

risks, injuries, and prevention programs. The team’s goal was

to reduce patient and employee injuries by building and

implementing a comprehensive Safe Patient Handling pro-

gram. The team is led by the central office patient safety

coordinator and employee health director with team mem-

bers from risk management, nursing leadership, education

services, and frontline staff from each clinical program (such

as surgical services, therapy, imaging, nursing, and others).

Creating a Systemwide Safe Patient Handling

Program

Analyzing the Current State

The team began with analysis of data. It was noted that

between 2004 and 2007, the average number of injuries for

all employees was 205 per year at a cost of $1,483,880. In

addition, during the same four-year period an average of

25–30 employees were permanently placed on disability.

Since it generally takes 12–18 months to rehire and retrain

replacements, this is a significant system loss. Injury reports

further demonstrated that high risk activities included reposi-

tioning patients (26%), catching a falling patient (17%), and

lateral transfers on or off stationary tables or stretchers

(22%). Data on patient events/injuries related to lifting and

transfers were also analyzed and showed a four-year average

of 219 injuries per year with an annual average cost of

$72,019. The most common areas in which patient injuries

occurred were general medical-surgical units, inpatient reha-

bilitation, imaging, and orthopedics.*

The team next examined the experiences of two IH hospitals

that had implemented Safe Patient Handling programs previ-

ously and conducted a return on investment analysis. The

first hospital, a 25-bed community facility, successfully

reduced their employee injuries five-fold within one year of

implementing a patient assessment procedure, a lifting team,

staff education, and careful monitoring and feedback.

Similarly, a three-fold reduction in injuries was realized at the

second hospital, a 245-bed medical center.* The center had

also targeted staff education, use of lifting equipment, and

careful monitoring with feedback to staff and leadership.

Although a Safe Patient Handling program requires a signif-

icant investment in equipment, a 30% reduction in

employee injuries was projected at IH, resulting in a poten-

tial two-year payback. The following potential barriers were

identified: funding for lift equipment purchase; resources for

education; new assessment tools, policies, procedures and

forms; and changing the practice of health care workers (see

Case Study Sidebar 3-1, page 72).

Developing and Implementing a Plan

The transfer and lifting team began with objectives for

developing a safe patient handling program that:

• implemented a cultural change for safe patient handling,

with a focus on the right mix of people and equipment

• established lift and transfer standards for patient-care

practices

• included standardized employee education and training

• evaluated and recommended appropriate equipment for

transfer and lifting tasks

• reduced employee and patient injury rates

Key elements for program success included commitment

from central office leadership that secured the resources for

equipment purchase, mid-level management to support new

policies, protocols and front-line participation to implement

patient assessment, and care planning requirements. A mul-

tidimensional program design resulted that included the

following:

• Well-trained employees with facility- and unit-level

champions

• Mechanical lift and transfer devices, lateral-transfer air

mattresses, gait belts, slide sheets, and slide boards

• Standardized protocols and tools

• Patient assessments

• Monitoring of outcomes

• Leadership support

Patient assessment is completed on admission, daily, and

when there is a change of condition using special nursing

CASE STUDY 3-2: INTERMOUNTAIN

HEALTHCARE: AN INTEGRATED EMPLOYEE

AND

PATIENT SAFE HANDLING PROGRAM

assessment tools that are imbedded into existing charting

(computer and paper). The assessment results in the

assignment of one of the following safe patient handling

categories:

• Maximum/Full Assist: Two staff members and a

mechanical lift device

• Moderate/Partial Assist: One staff and powered lift

device or a gait belt

• Minimum/Standby: Stand by to help if needed

• Independent

Wall signs depicting the scoring tool with category criteria

are posted at the head of the patient’s bed and in staff rooms

to provide visual reminders (see Case Study Figure 3-2, page

73). Charting forms incorporate the tool in the medical

record for seamless documentation. The computerized tool

has decision logic built in to use other patient assessment

information and to prompt for specific actions. Staff educa-

tion includes both hands-on classes as well as computer-

based training for new equipment, policy and assessment

tools, and skills pass-off checklists. Patients also receive fact

sheets with information about safe lifting and transfer prac-

tices and procedures. Facility specialists and department

level champions within each hospital support program

implementation and sustained improvement. Electronic

reports for program analysis are available at the departmen-

tal, campus, regional, and system level. After almost two

years of research, development, and planning, the program

was officially launched in 2008 through a progressive quar-

terly implementation across hospital regions; for example,

Urban South (consisting of five hospitals) went first.

Meeting Program Objectives—Sharing Important

Lessons

After one year of program implementation (2008–2009) IH

employee injury rates were reduced by 42% and patient falls

related to transfer were reduced by 45%. By year-end 2010,

IH saw a 41% reduction in employee injuries compared to

presystem rates and a 49% reduction in patient falls related

to lift and transfer activities. The estimated cost savings for

employee injuries systemwide is $500,000 per year across

the hospitals. There was also a 15% increase in positive

responses to the statement, “In my department, we have

enough time and resources to safely care for our patients” on

the annual employee opinion survey from 2008 to 2009

survey results.

Ensuring initial and ongoing program success requires more

than mandates. Recognition and elimination of barriers is

essential when instituting any change in organizational cul-

ture. Active leadership, facility level coordination, system

oversight and support of facility specialists, thorough

employee education, and adequate resources are critical.

Clinical champions increase program acceptance, while

departmental managers hold staff accountable for assessment

and appropriate use of safe patient handling category-

specific recommendations. Data analysis of injuries and cost

savings provides feedback to leadership and staff on value

and improvement goals. In 2011, IH added equipment

resources and undertook an awareness campaign that

included posters, stories, skill day fairs, and prize drawings.

At Intermountain Healthcare, the Safe Patient Handling

program is providing “extraordinary care” to patients and

employees.

Source

* Conti MT, et al. Is your facility equipped for safe patient han-

dling? Nurs Manage. 2011 April;42(4):46–47.

3.1.2 Slip, Trip, and Fall

Slip, trip, and fall (STF) injuries are the second-most com-

mon cause of lost workday injuries in hospitals

and present

a significant risk in nursing homes and other health care

facilities, as well.

Injuries from falls account for a significant portion of health

care workplace injuries.

These injuries are generally catego-

rized as falls from elevation or falls on the same level, with

the latter being much more common, accounting for 60%

of total falls.

Unlike construction where the majority of falls

occur from elevation, 89% of the STF incidents in hospitals

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Case Study Sidebar 3-1:

Potential Barriers to Safe

Patient Handling Initiatives

1. It takes too much money.

2. It takes too much time.

3. It is not a problem here.

4. It is more work to assess patients.

5. Leadership commitment is lacking.

6. Measurement of outcomes is difficult.

7. Educational resources are lacking.

8. It requires changing patient care paradigms.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

Case Study Figure 3-2: Safe Patient Handling: Repositioning and Lifting

Pediatric Adult Scoring Tool

Source: Intermountain Healthcare. Salt Lake City, UT. Used with permission.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

occur on the same level and 11% were falls from elevation

that primarily occurred on stairs (6.9%) and from stepstools

and ladders (1.7%).

Risk Factors for STF in Health Care

Settings

Risk factors are varied and range from structural elements

to health care worker footwear. They can occur when

there is an unexpected change in contact between an indi-

vidual’s feet and the flooring surface.

Hazards begin with

exterior areas of the health care facility, such as parking

structures, walkways, stairs, and entrances. Potentially

dangerous conditions can be produced by weather-related

elements, such as rain, ice, or snow. These factors also

contribute to wear and tear on structural elements such as

concrete and, if poorly maintained, can result in broken

and uneven surfaces. External risks are magnified if there

is poor lighting.

Health care facilities have multiple departments with varied

risk factors. For example, areas involved in the preparation,

delivery, serving, and clean-up of food are at high risk for

wet, greasy, and slippery floors, as evidenced by the high

rates of STF injuries experienced by food service workers.

Because of their representation in the hospital workforce,

nursing staff are the occupational group with the greatest

total number of STF-related workers’ compensation

claims.

Most walking surfaces in hospitals are slip-resistant when

they are clean and dry. Contaminants on the floor, such as

water, body fluids, spilled drinks, and grease are the lead-

ing cause of STF injuries in hospitals.

12,13

Specialized treat-

ment areas such as the emergency and operating rooms,

pharmacy, and radiology may have unique risks.

Throughout the health care setting the presence of equip-

ment, scrub sinks, and the need for frequent or specialized

cleaning protocols can also contribute to the risk of STF

injuries.

3.1.2.1 Impact on Workers and Patients

Although fall prevention in hospitals typically focuses on

patients, it is important to recognize the impact on work-

ers, visitors, and others as well. In 2010 a total of 12,400

STF injuries accounted for 21% of all work-related

injuries in hospitals requiring at least one day away from

work.

Also, the BLS reported that the incidence rate of

lost-workday injuries from same-level STF injuries in hos-

pitals was 33.8 per 10,000 full-time equivalent (FTE)

workers, which is 73% higher than the average rate for

private industry (19.5 per 10,000 FTE).

Older workers (male and female) experience higher rates of

injury than younger workers, while female health care work-

ers have higher rates of STF injuries than their male coun-

terparts.

In addition to direct-care staff, organizational

employees ranging from auxiliary to support personnel,

administrative staff, and especially food service workers,

experience STF injuries. Visitors, students, medical staff,

volunteers, and others also are at risk for STF injuries

within the facility.

Patient falls in health care facilities are a primary safety con-

cern and an identified National Patient Safety Goal for the

long term care and home care Joint Commission accredita-

tion programs.

Multiple factors place patients at risk for

falls while in health care facilities, including compromised

cognitive and physical status, disorientation, effects of med-

ication, age, and balance and mobility issues. In a multiyear

analysis of 7,082 inpatient falls across nine hospitals in a

midwestern health care system, it was found that 1,868

(26.4%) resulted in some type of injury, and 169 (2.4%)

resulted in moderate or serious injury.

Falls cause physical

harm and psychological distress, and fall-related injuries can

impair rehabilitation, increase length of stay, and escalate

the cost of care.

3.1.2.2 Examples of Interventions

Interventions to reduce the risk of falls will often benefit

patients and workers alike. Research has been undertaken to

identify solutions and develop fall prevention programs for

targeted populations based on empirical evidence of risk

reduction. With regard to patients, a Cochrane

Collaboration systematic review of 41 randomized con-

trolled trials of interventions for preventing falls in older

people in nursing care facilities and hospitals found multi-

factorial team-based interventions to be effective.

Regarding employee falls, a recently completed 10-year

multidisciplinary trial by Bell et al.

demonstrated that a

comprehensive STF prevention program can be highly

effective for reducing the rate of STF workers’ compensa-

tion claims. Components of the program ranged from use

of slip-resistant surfaces, such as nonslip shoes and floor-

ing, water-absorbent mats, hazard assessments, and keep-

ing floors clean and dry. After examining past injury

records, interviewing workers who experienced a fall, and

studying the performance of slip-resistant surfaces, their

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

findings confirm that many fall-related injuries could be

prevented by mitigating risk factors. Study recommenda-

tions begin with conducting a hazard assessment of the

facility and outside areas to discover environmental condi-

tions that might increase the risk for an STF. Suggested

examples of specific interventions to prevent falls include

those shown in Sidebar 3-2.

Other interventions include providing adequate lighting,

hand rails, and grab bars and installing high-tech flooring

that contributes to slip prevention and reduces foot fatigue.

While some fall prevention interventions involve significant

resources, they can also be low cost. An example of a simple,

economical but effective intervention is described in Case

Study 3-3, page 76.

• Housekeeping

– Keep walkways clear of objects and reduce

clutter.*

†

– Address the risk from electrical and equipment

cords in the following ways:

❍

Secure loose cords and wires with cord organ-

izers in patient rooms, operating rooms, com-

puter stations, and other high-traffic areas.*

†

❍

Use retractable cord holders for phones in

patient rooms and nursing stations.*

❍

Cover cords on floor with a beveled protective

cover.*

❍

Organize operating rooms to minimize equip-

ment cords across walkways.

†

• Ice and snow removal

– Prominently post and disseminate contact informa-

tion (telephone or beeper numbers) for snow

removal staff.*

†

– Encourage home health and maintenance workers

to use ice cleats.*

†

– Conveniently place bins of ice-melting chemicals

near outdoor stairs and heavily traveled walkways

so that any employee can apply them if they

notice icy patches.*

†

References

* US Department of Health and Human Services, Centers for

Disease Control and Prevention, National Institute for

Occupational Safety and Health [Internet]. Atlanta (GA):

Centers for Disease Control and Prevention; 2010 Dec

[updated 2011 Jan 12; cited 2011 Aug 19]. Slip, Trip, and

Fall Prevention for Healthcare Workers, DHHS (NIOSH)

Publication Number 2011-123; [about 56 p.]. Available from:

http://www.cdc.gov/niosh/docs/2011-123/.

† Collins J. Chapter 12: Slip, Trip, and Fall Incidents. In: US

Department of Health and Human Services, Centers for

Disease Control and Prevention, National Institute for

Occupational Safety and Health [Internet]. State of the

Sector | Healthcare and Social Assistance: Identification of

Research Opportunities for the Next Decade of NORA.

DHHS (NIOSH) Publication Number 2009-139. Available

from: http://www.cdc.gov/niosh/docs/2009-139.

Sidebar 3-2: Interventions to

Prevent Falls

Specific interventions to prevent falls include the

following:

• Keep floors clean and dry. Contaminants on walking

surfaces such as water, grease, and soap are com-

mon risk factors in health care facilities.

– Promote prompt reporting of observed hazards

(such as spills and obstructions) by patients and

visitors, as well as staff.*

– Encourage workers to clean or cover spills

promptly.*

– Install spill clean-up materials such as wall-

mounted spill pads or paper towel dispensers

throughout the facility and near drinking fountains

for quick and easy access.*

†

– Make floor signs readily available to warn of wet

or slippery floors.*

†

– Place umbrella sleeves/bags available near build-

ing entrances.

†

– Place water-absorbent mats with beveled edges

as wide as the entrance area. Ideally, mats should

be of sufficient size to remove all water, ice, and

snow from the soles of shoes, so that no tracks

are on the flooring surface beyond the last mat.*

– Prominently post and disseminate housekeeping

contact information (telephone or beeper num-

bers) as part of a general awareness campaign.*

• Prevent entry to wet areas

– Use barriers and special signage to block access

to wet areas.*

– Block off areas where floor wax is being stripped

or applied and use a doorstop to prevent wax

overflow to adjacent areas.*

– Promptly remove (within 10 minutes) “wet floor”

signs when flooring is dry.*

†

Kaiser Permanente, Mid-Atlantic States Region

Kaiser Permanente is an integrated care consortium, providing

care throughout eight regions in the United States. The Mid-

Atlantic Region encompasses the vicinity of Washington,

D.C., including Maryland and Virginia. Kaiser Permanente’s

commitment to a safe and healthful workplace is established:

An injury-free workplace is an essential ingredient of high-

quality, affordable patient care. Kaiser Permanente has set the

goal of eliminating all causes of work-related injuries and ill-

nesses, so as to create a workplace free of injuries.

The Kaiser Permanente Mid-Atlantic States (MAS)

Workplace Safety Department consists of two individuals, a

labor Workplace Safety Coordinator and a management

partner. This department works closely with the Mid-

Atlantic States leaders accountable for health care delivery

and operations, physician partners, labor leaders, shop stew-

ards, frontline teams, and staff to engender a culture of

safety across the organization. Examining STF data from

wet floors and common wet floor conditions at building

entrances due to water dripping off wet umbrellas in 2007,

the Mid-Atlantic States Workplace Safety Coordinator,

management partners, and frontline team representatives

pursued an intervention to reduce this fall risk at building

entrances. Data showed that STF injuries were experienced

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Resources 3-2: Slips, Trips, and Falls

Title and Website Description

National Institute for Occupational Safety and Health (NIOSH)

Publication

Slip, Trip, and Fall (STF) Prevention for Healthcare Workers

http://www.cdc.gov/niosh/docs/2011-123/pdfs/2011-123.pdf

Discusses hazards for STF injuries in health care

facilities. It also provides specific preventive

strategies.

National Safety Council (NSC)

Information and Links

http://www.nsc.org/safety_home/Resources/Pages/Falls.aspx

Links to topics areas on falls prevention and general

information.

Occupational Safety and Health Administration (OSHA)

Hospital Training Tool

Hospital eTool

http://www.osha.gov/SLTC/etools/hospital/index.html

A stand-alone, interactive, Web-based training tool on

occupational safety and health topics. This eTool

focuses on some of the hazards and controls found

in the hospital setting and describes standard require-

ments as well as recommended safe work practices

for employee safety and health.

Standards

29 CFR 1910 – OSHA Standards

http://www.osha.gov/SLTC/healthcarefacilities/standards.html

Standards for health care facilities. Standards

addressing flooring conditions and flooring safety are

included.

CASE STUDY 3-3: KAISER PERMANENTE:

IMPLE STEPS IMPROVE SAFETY—

A S

LIP, TRIP, FALL (STF)

REVENTION MEASURE

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

by employees, physicians, patients, visitors, and others. A

region-wide goal to reduce the overall number of STF

injuries was established for 2008 and has been progressively

reset with each new year. The goal was to reduce the actual

number of STF incidents due to wet floors by 10–15% each

year. In April 2008, umbrella sleeves were introduced as one

measure of multiple Workplace Safety performance

improvement projects that resulted in a reduction in the

number of STF injuries. Use of plastic umbrella sleeves/bags

demonstrates how a relatively simple intervention helped

contribute to achieving Workplace Safety goals and how this

simple measure helped with integrating patient and

employee safety efforts and outcomes.

Deploying and Using Umbrella Sleeves/Bags to

Reduce STF Risk

Multiple departments including Workplace Safety,

Environmental Health & Safety, Employee Health, Nursing,

and patient care areas partnered in the successful deploy-

ment of the umbrella sleeves. In particular Security, Building

Operations, Volunteers, Workplace Safety, and Purchasing

departments were involved in plan implementation. Key

activities of program planning included identifying and

designing a device to store and dispense the sleeves and sig-

nage to inform everyone entering the building of umbrella

sleeve/bag availability as well as instructions for use.

General communications highlighting objectives and activi-

ties related to reducing STF injuries were circulated in 2008

and 2009. Currently, data on the initiative and STF injuries

are updated and shared on a regular basis through several

communication vehicles, such as a Workplace Safety injury

data website, posters, meetings, seminars, and forums. To

further raise awareness STF injuries were featured topics of

posters, the “Ten Foot Circle” and “You Can Make a

Difference” distributed in 2010 and 2011, respectively. These

posters are placed in highly visible locations throughout each

building, such as staff break areas and lobby bulletin boards.

Efforts to reduce STFs associated with wet floors appear to

have led to a reduced incidence since program implementa-

tion. A total of eight patient falls associated with wet floors

was reported between 2006 and 2011, which may have been

positively impacted by this program. A breakdown of

employee STF injuries associated with wet flooring is pro-

vided in Case Study Table 3-1.

Expanding the STF Prevention Program

Umbrella sleeves provide a cost-effective intervention that

reduces the incidence of wet floors and associated fall risk.

Future plans include expanding the program to other

regions within the Kaiser Permanente system and investigat-

ing ways to make the bags reusable as part of environmental

stewardship. The umbrella sleeve intervention is now com-

plemented by additional actions known to reduce flooring-

related fall risks. These actions include the following:

• In 2009 and subsequent years, flooring in the medical

centers has been replaced with a lower-risk-for-slip floor-

ing product and/or hardwood floors with a low-slip sur-

face. These changes in flooring addressed the STF risk in

carpeting that buckled and/or had frayed edges. Lower-

risk-for-slip flooring is now recommended for new

Kaiser Mid-Atlantic States renovation and construction

projects.

• In areas with sinks, the hand-washing soap product was

exchanged to a foam soap product thereby reducing the

risk for slips from highly slippery soap drips and soap

residue.

• In all facility remodels starting 2009–2010, thick fabric

mats were installed at building entrances for wicking

moisture and removing debris from footwear (similar to

function walk-off mats).

In combination with engineering and design changes, and as

part of a comprehensive program, the umbrella sleeve inter-

vention lowers the risk for STF injuries associated with wet

flooring. Kaiser Permanente successfully applied perform-

ance improvement methods and brought together key stake-

holders to effectively target a safety issue affecting patients,

health care workers, and visitors.

Case Study Table 3-1: Percentage

of Employee Falls Due to

Wet Flooring

Performance

Year

Total

Employee

STF Injuries

Number Due

to Wet

Floors

% Total Falls

PY 2009 70 15 21

PY 2010 76 9 11.8

PY 2011

(through

3-31)

59 6 10

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

3.2 Sharps Injuries and

Infection Transmission

3.2.1 Sharps Injuries and Bloodborne

Pathogen Exposures

Infectious diseases acquired through occupational exposure

to bloodborne pathogens as a result of sharps injuries (per-

cutaneous) or contaminated blood and body fluids (muco-

cutaneous) present a serious concern for both health care

workers and patients. Data from the World Health

Organization (WHO) indicates that worldwide 2 million

out of 35 million health care workers experience percuta-

neous exposure to infectious diseases each year

while the

Centers for Disease Control and Prevention (CDC) esti-

mates as many as 385,000 sharps injuries are incurred by

hospital-based personnel each year in the United States.

2008 survey by the American Nurses Association revealed

that 64% of nurse respondents reported having an acciden-

tal sharps injury.

Sharps include needles and other devices such as scalpels

that can result in a percutaneous injury to the person using

or handling them. Hepatitis B virus (HBV), hepatitis C

virus (HCV), and human immunodeficiency virus (HIV)

are well-known pathogens associated with disease transmis-

sion from sharps injuries; however, the risk could include

more than 20 others.

In addition to percutaneous injuries,

handling blood and body fluids that may be contaminated

also presents a risk for occupational disease transmission.

In the 1990s, increased attention to sharps injuries in the

health care workforce resulted in legislation, product research

and development, implementation of injury surveillance sys-

tems and identification of risk mitigation strategies.

Despite

legislation at the national and state level mandating preven-

tive activities, significant risk remains for health care workers

and patients. Research continues to show that many blood-

borne pathogen exposures could be prevented by compliance

with recognized safety strategies.

23,25–28

Sharps injuries occur across many professional disciplines

and health care settings. Available statistics suggest that

nurses and surgeons are at the greatest risk.

29–31

According to

surveillance data from 2008 in Massachusetts, 38% of

injuries were incurred by nurses.

Similarly, data collected

by the CDC between 1995 and 1999 also showed that 44%

of injuries were incurred by nurses.

During the same

reporting periods, physicians incurred 36% and 30% of

injuries respectively. Other health care workers with

reported sharps injuries include surgical residents and tech-

nicians, medical and nursing students, nursing assistants and

orderlies, phlebotomists, and lab workers. When improperly

disposed of, sharps can place housekeeping and other sup-

port staff at risk as well. To address this issue, multiple leg-

islative guidelines and policies developed between 1987 and

2000 included recommendations relevant to the design and

function of safe disposal containers resulting in a marked

decline in the percentage of disposal-related sharps injuries.

Underreporting is a significant issue across all disciplines

and is complicated by many factors including fear, lack of

time, punitive outcomes, inadequate reporting and post-

exposure protocols, and misperception about the level of

risk. Estimates of unreported needlestick injuries range from

30% to 73%.

33,34

Sharps injuries can occur in any setting where devices are

used. Current surveillance systems receive data almost exclu-

sively from hospitals but could serve as models for injury

tracking in other settings, such as long term care, home care,

medical clinics, and outpatient centers (e.g., surgical and

dialysis).

Within hospitals, the patient room and surgical

units are some of the highest exposure risk locations.

Introduction of the Needlestick Safety and Prevention Act of

2000 led to a significant overall decrease in sharps injuries in

nonsurgical settings; however, there was a noticeable increase

in the proportion of injuries connected with the use of

safety-engineered devices, implying increased deployment of

this technology.

However, in surgical settings the overall

injury rate increased during the same period and the inci-

dence of injuries associated with safety-engineered devices

was less than 1%, reflecting minimal use of this technology.

Sharps injuries present a risk in the home health setting as

well. A study to examine sharps injuries in nine home health

care agencies from 2006 to 2007 documented an annual

injury incidence rate of 5.1 per 100 FTE nurses and 1.0 per

100 FTE aides,

while two other surveys of home care

nurses found 13% (9 of 72 nurses)

and 8.5% of 164

nurses had experienced a sharps injury in the previous 12

months.

Additionally, family members and informal care-

givers in the home care setting are also at risk.

3.2.1.1 Impact on Patients and Workers

Sharps injuries place the health care worker and patient at

risk for exposure to infectious diseases. In addition to percu-

taneous injury, workers are at risk for mucous membrane

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

and skin exposures to contaminated blood and body fluids.

The actual risk for occupational transmission of pathogens

varies for each organism. For example, the average risk for

HIV transmission after a percutaneous exposure is estimated

to be 0.3%

while HCV ranges from 0.5% to 10% follow-

ing a single needlestick exposure.

The advent of the hepati-

tis B vaccine has resulted in an incidence of HBV in health

care workers that is significantly lower than the general pop-

ulation.

Fortunately, occupationally acquired HIV and

HCV are rare events; however, exposures still carry the risk

of other infections and adverse outcomes.

2,22,34

The issue of transmission of infectious diseases from health

care workers to patients is an area of increasing interest.

Transmission of bloodborne pathogens from health care

workers to patients has been primarily reported in cases of

infected surgeons performing exposure-prone procedures

(orthopedic, for example). In fact, worldwide cases of health

care worker-to-patient transmission of HIV between

1991–2005 and HBV between 1991 and 2005 all occurred

in surgical settings.

Under-reporting of exposure incidents

may be a factor in determining the impact on patients.

Perry et al.

and others have called for improved national

level reporting of patients exposed to health care workers’

blood and monitoring of infection rates for those individu-

als. Somewhat more common, however, is the risk of trans-

mission from a drug-using infected employee to patients.

Recent narcotic diversion incidents in which a cardiac

catheterization lab technician and a radiology technician

were suspected of reusing contaminated syringes resulted in

the need for thousands of patients to be tested.

40,41

The impact of these injuries is both direct and indirect.

Exposed individuals, patients, or workers face possible ill-

ness and associated outcomes—both physical and emo-

tional. An exposure may trigger fear and anxiety in the

individual and the family as the exposed individual is

monitored for possible seroconversion.

In addition to the

potential for adverse health outcomes, injury-related costs

may include medical treatment, lost wages, workers’ com-

pensation, and legal liability. Lastly, trust between

patients, health care workers, and organizations may be

diminished.

3.2.1.2 Examples of Interventions

Evidence shows that there are successful strategies and

interventions that dramatically reduce the risk of a sharps

injury. A range of safety-equipped injection devices have

been developed over the past 20 years. Coupled with

ongoing educational efforts, there has been a reduction in

injury rates. Frontline staff should be involved in the eval-

uation and selection of specific products. However, intro-

ducing safety devices alone is not enough. When possible,

other methods of medication administration should be

substituted. Health care organizations should provide

administrative structures such as policies and procedures

to support the consistent and effective use of selected

safety devices.

When working outside of institutional settings and con-

trolled environments, plan ahead prior to performing high

risk procedures by establishing adequate work space, device

handling and disposal methods, and obtaining safety-

engineered devices and patient handling equipment when-

ever possible. For example, in home health care, devices and

equipment design typically varies across patients and may be

new or unfamiliar to the nurse. Additionally, patients in the

home may reuse equipment or improperly dispose of used

equipment, placing health care staff and family members at

risk.

34,35

Safe practice is further complicated by the fact that

each home environment is unique and may present unsafe

working conditions. Home care nurses report that work set-

tings are sometimes dirty, crowded, and complicated by

poor lighting and other distractions.

Examples of interventions that successfully reduce the risk

and incidence of sharps injuries and bloodborne pathogen

exposures across health care settings are well documented.

Administrative actions include the following:

• Institute a systematic approach to bloodborne pathogen

exposure prevention including: employee education pro-

grams, policies, and procedures to support injury pre-

vention, reporting, and postexposure protocols.

• Assess the organization’s risks and injury experience

through a review of available reports, injury surveillance,

and staff survey.

• Eliminate unnecessary invasive procedures in favor of

safer alternatives when appropriate.

34,42

• Organize a multidisciplinary quality improvement team,

conduct a baseline assessment, set priorities of an action

plan, and implement improvement interventions.

• Assess the impact of prevention activities through feed-

back, data collection, and analysis, and modify activities

as needed.

• Offer vaccine to persons with the potential for exposure

to HBV and other bloodborne pathogens.

• Provide easy access to efficient systems for postexposure

prophylaxis to prevent HIV transmission.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Examples of behavioral controls include the following:

• Avoid recapping needles using two hands.

26,42

• Use safe needle disposal methods and materials.

34,35,42

• Use blunt suture needles instead of sharp ones and use

safety-engineered instruments when available and feasi-

ble.

25,26,34,42

• Avoid hand-to-hand passing of instruments in the surgi-

cal setting—create neutral zones or designated fields for

instrument transfers to avoid simultaneous handling by

personnel.

2,25,26

3.2.1.2.1 Safe Injection Practices: The CDC’s “One and

Only” Campaign

“Preventing the spread of bloodborne pathogens,

particularly hepatitis B virus (HBV), hepatitis C

virus (HCV), and human immunodeficiency virus

(HIV), represents a basic expectation anywhere

health care is provided. This is true both in terms of

patient and provider protections. Health care should

provide no avenue for the transmission of these

potentially life-threatening infections; yet, unsafe

medical practices continue to contribute to much of

the worldwide disease burden that is associated with

HBV and HCV.”

43(p.137)

The One & Only Campaign is a public health campaign,

led by the CDC and the Safe Injection Practices Coalition

to raise awareness among patients and health care

providers about safe injection practices.

The campaign

aims to eradicate outbreaks resulting from unsafe injection

practices.

As described by CDC, unsafe injection practices put

patients and health care providers at risk of infectious and

noninfectious adverse events and have been associated with

a wide variety of procedures and settings. Investigations by

state and local health departments and the CDC have iden-

tified improper use of syringes, needles, and medication

vials when administering routine injections.

These prac-

tices have resulted in:

• Transmission of bloodborne viruses, including HCV to

patients

• Notification of thousands of patients of possible expo-

sure to bloodborne pathogens and recommendation that

they be tested for HCV, HBV, and HIV

• Referral of providers to licensing boards for disciplinary

action

• Malpractice suits filed by patients

The campaign, which engages more than 20 public and pri-

vate organizations, focuses on educating health care

providers on the following basic safety messages:

• Do not use needles and syringes for more than one

patient or reuse to draw up additional medication.

• Do not administer medications from a single-dose vial or

IV bag to multiple patients.

• Limit the use of multidose vials and dedicate them to a

single patient whenever possible.

In April 2011, Premier Healthcare Alliance hosted “Safer

Designs for Safer Injections: Innovations in Process,

Products, and Practices,” a meeting of more than 200 key

stakeholders. The goal of the meeting was to advance injec-

tion safety by raising awareness and continuing the national

dialogue on expanding safer, innovative approaches and

product designs to protect patients and prevent infections.

In addition to the need for more educational outreach, par-

ticipants recognized the continuing pressure for reducing

health care costs and recommended greater clinician

involvement in purchasing decisions across all delivery

settings.

3.2.2 Preventing Transmission of

Infectious Diseases

Infectious disease transmission by direct and indirect

exposure is perhaps the most visible health risk underscor-

ing the connection between health care personnel and

patients. Occupational health and infection preventionists

(IPs) have traditionally worked toward shared goals of pre-

venting, tracking, recording, and reporting (where indi-

cated) the occurrence of infectious diseases in health care

organizations. Epidemics, especially recent influenza out-

breaks, have increasingly drawn these professionals

together across health care organizations and settings. In

fact, in a few organizations, these roles may even be com-

bined, making a strong case example for the synergy

between health care worker and patient health interven-

tions. The increasing complexity of the health care envi-

ronment has expanded the scope of work for IPs to

include oversight of employee health services related to

infection prevention.

However, significant opportunities

exist to enhance collaboration in preventing infection

among health care workers, patients, and the community

at large. An in-depth discussion of infection prevention

and control is beyond the scope of this monograph.

However, this section will draw attention to recognizing

the shared goals and interventions that protect employees

and patients from disease transmission and infection.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

Resources 3-3: Sharps Injuries

Title and Website Description

American Nurses Association (ANA)

Needle Safety

http://www.needlestick.org

Brochures, fact sheets, CE module, and toolkits for

nurses and employers

Massachusetts Department of Health and Human Services

The Massachusetts Sharps Injury Surveillance and Prevention Project

http://www.mass.gov/dph/ohsp

State mandated reporting system for sharps injuries

among hospital workers

National Institute for Occupational Safety and Health (NIOSH)

Bloodborne Infectious Diseases: HIV/AIDS, Hepatitis B, Hepatitis C:

Preventing Needlesticks and Sharps Injuries

http://www.cdc.gov/niosh/topics/bbp/sharps.html

Multiple and diverse online resources and links to

alerts, publications, workbooks, surveillance data,

educational/training materials, and case studies

NIOSH Alert

Preventing Needlestick Injuries in Health Care Settings. DHHS

(NIOSH) Publication No. 2000-108

http://www.cdc.gov/niosh/docs/2000-108/

NIOSH Alert providing recommendations and refer-

ences for employers and workers related to prevent-

ing needlestick injuries

Bulletin

Use of Blunt-Tip Suture Needles to Decrease Percutaneous Injuries to

Surgical Personnel: Safety and Health Information Bulletin

DHHS (NIOSH) Publication No. 2008-101

http://www.cdc.gov/niosh/docs/2008-101/

The bulletin is advisory in nature, informational in

content, and is intended to assist employers in pro-

viding a safe and healthful workplace. The purpose is

(1) to describe the hazard of sharp-tip suture needles

as a source of percutaneous injuries to surgical per-

sonnel; (2) to present evidence of the effectiveness of

blunt-tip suture needles in decreasing percutaneous

injuries to surgical personnel, particularly when used

to suture muscle and fascia; and (3) to emphasize

OSHA’s requirement and NIOSH’s recommendation

to use safer medical devices—in this case, blunt-tip

suture needles—where clinically appropriate.

Workbook for Designing, Implementing, and Evaluating a Sharps

Injury Prevention Program

http://www.cdc.gov/niosh/topics/bbp/sharps.html

A workbook designed for infection preventionists,

occupational health personnel, health care adminis-

trators, and others to help prevent needlesticks and

other sharps-related injuries to health care personnel

STOP STICKS Campaign

Sharps Injuries—Bloodborne Pathogens

http://www.cdc.gov/niosh/stopsticks/bloodborne.html

This webpage by NIOSH’s “Stop Sticks” campaign

raises awareness of the various types of diseases

that can be potentially transmitted through needle-

stick injuries.

University of Virginia Health System

EPINet, International Health Care Worker Safety Center, University of

Virginia

http://www.healthsystem.virginia.edu/pub/epinet

Information and resources relating to percutaneous

injury, including reports on data from the EPINet sur-

veillance system

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

A consensus panel,

convened to develop recommenda-

tions for the infrastructure and essential activities for

infection control in hospitals, identified the following

goals of an infection control and prevention program:

• Protect the patient.

• Protect the health care worker, visitors, and others in

the health care environment.

• Accomplish the previous two goals in a cost-effective

manner, whenever possible.

These goals can be applied in any setting where patients

and health care workers interact. Preventing the transmis-

sion of disease to individuals requires attention to the var-

ious modes of transmission. These modes include contact

(direct and indirect), droplet, and airborne.

Infection control guidelines recommend implementation

of infection control practices that have shown to decrease

the transmission of infectious agents. However, several

observational studies have revealed that adherence to these

recommendations by health care personnel ranges from

43% to 89%, depending on the circumstance in which

they were used (for example, 92% adherence to glove use

during arterial blood gas collection).

The CDC

Guideline for Isolation Precautions: Preventing Transmission

of Infectious Agents in Health Care Settings

has noted that

health care workers often perceive their compliance to be

higher than actual observed performance. Traditional

interventions that are used to increase compliance, such as

education, enhance knowledge levels but may not change

behaviors. Multifaceted approaches that combine new ele-

ments, such as engineering controls, facility design con-

cepts, or the use of electronic monitoring and voice

prompts for hand hygiene, are being explored.

One of the most significant infection control concerns is

the risk of patients developing an infection while in a

health care organization. Infections unrelated to the con-

dition for which patients are being treated in a health care

facility are often referred to as healthcare associated–

infections (HAIs). HAIs are sometimes linked to the use

of devices as in catheter-associated urinary tract infections

(CAUTI) and central line–associated blood stream infec-

tions (CLABSI). Other infections are associated with drug

resistant organisms known to be present in health care

facilities, such as methicillin-resistant Staphylococcus aureus

(MRSA). MRSA is one example of several bacteria that

have become resistant to one or more class of antimicro-

bial agents and as a group are identified as multidrug-

resistant organisms (MDROs). A study of patients in

2002 estimated that HAIs accounted for an estimated

1.7 million infections.

Infections in nursing home residents are estimated to

result in 150,000 to 200,000 hospital admissions per year,

and when infection is the primary admitting diagnosis,

the death rate can reach as high as 40%.

It is further

estimated that nursing home residents incur an average of

1.6 to 3.8 infections annually.

Efforts to prevent and

reduce HAIs have received extensive attention from regu-

latory, public health, and professional organizations as

well as the media and watchdog groups. These efforts

have become a national priority. Additional information

on initiatives may be found at http://www.hhs.gov/ash

/initiatives/hai/infection.html.

Some infections (for example, drug-resistant tuberculosis)

may be more prevalent in particular geographic locations

or certain populations outside the acute care setting.

However, in a world that can be traversed in mere hours,

safety is not guaranteed by distance, further highlighting

the importance of taking a comprehensive view toward

prevention.

The Severe Acute Respiratory Syndrome

(SARS) epidemic in 2003 was a wake-up call to the risks

for workers and patients, and further highlighted the need

for effective safety systems in health care.

This infection

first occurred in southern China and rapidly spread

throughout the world, eventually resulting in 774

deaths;

51% of the deaths in a Canadian outbreak were

health care workers.

Annual seasonal influenza outbreaks

along with newer and more virulent flu strains, as well as

fears of a pandemic outbreak, make this a critical issue

that requires collaborative occupational and patient health

initiatives at the organizational level and as part of the

larger infection control community.

Infection is also a significant concern voiced by health

care professionals. A survey of Association of

Occupational Health Professionals members conducted in

August 2010 found infection was one of the top issues or

concerns.

Many concerns are related to sharps injuries

and subsequent exposures (see Section 3.2.1 Sharps

Injuries and Bloodborne Pathogen Exposures, page 78).

However, other infections and modes of transmission

also pose risks to health care workers. For example, the

recent surge of measles outbreaks includes documented

transmission of infection from patients to health care

workers.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

Influenza transmission between health care workers and

patients is an ongoing issue, and although the CDC has

recommended since 1984 that all health care workers be

immunized, estimates are that 30–50% of workers in

health care organizations are unvaccinated.

Health care

workers are at greater risk for contracting influenza than

are members of the general public, and the aging work-

force places many workers in higher risk categories. The

CDC has proposed a goal of 90% coverage to be included

in the Healthy People 2020 for health care personnel

influenza vaccination.

Also, The Joint Commission has

updated the standards addressing health care worker

influenza vaccination and expanded the settings for which

they apply. The new standards became effective July 1,

2012.

While frontline health care workers usually come to mind

first when considering infectious disease exposure and

transmission, all employees in the health care environ-

ment must be included in prevention planning. For exam-

ple, organizations must pay attention to risks of

transmission in food safety, waste disposal, lab and diag-

nostic services, and environmental cleaning. Similarly,

health care workers and patients in all settings are at risk

for infection transmission. Inpatient acute care settings

administer to the sickest and most vulnerable patients and

often involve treatment of the most serious infectious

organisms. However, any setting in which people interact,

such as physicians’ offices, outpatient clinics, inpatient

settings, long term care facilities, and patient homes pose

a risk for disease transmission. Noninstitutional settings,

such as home health, also lack the environmental and

engineering controls available in facilities that enhance

efforts to prevent infection transmission.

3.2.2.1 Impact on Patients and Workers

The impact of infections on patients and health care

workers is significant. Patients who develop HAIs can

experience a range of serious complications that in some

instances includes the risk of death. For example,

influenza can lead to the development of pneumonia and

complicate existing cardiopulmonary conditions.

many as 90% of all influenza-related deaths occur among

elderly patients. In addition to morbidity, HAIs increase

length of stay and significantly increase the costs of care.

Patient and family perceptions of and satisfaction with

care are likely to be diminished.

Health care workers who develop occupationally acquired

infections not only experience personal illness but risk

exposing family members. Employee absenteeism adds

costs to the organization (to replace the ill employee) and

increases health insurance expenditures. Protecting the

health of patients and workers from infectious diseases is a

hallmark of a safe workplace. Calculating the cost-benefit

ratio of utilizing specific prevention strategies and inter-

ventions is challenging. However, successful prevention of

disease transmission between health care workers and

patients leads to important cost savings for the organiza-

tion and health care insurer.

3.2.2.2 Examples of Interventions

Infection prevention and control is a vast topic for which

extensive evidence and many practice guidelines are avail-

able. Government public health and professional associa-

tions are rich resources for information (see Resources

3-4, page 86). An organizational safety culture with a

shared commitment to infection prevention for the safety

of patients and workers is created through (1) the actions

management takes to improve patient and worker safety,

(2) worker participation in safety planning, (3) the avail-

ability of appropriate protective equipment, (4) influence

of group norms regarding acceptable safety practices, and

(5) the organization’s socialization process for new

personnel.

Interventions to prevent transmission of infectious dis-

eases are often identified within the hierarchy of controls

(see page 34). Administrative controls are directed at the

early detection of infectious diseases in workers or

patients and include screening mechanisms (such as med-

ical histories), testing (such as a TB skin test), and policies

and procedures detailing referral and treatment protocols.

Examples of engineering controls include special building

design (for example, isolation rooms) and mechanical sys-

tems such as high-efficiency particulate air (HEPA) filters

and ventilation systems.

Personal protective equipment

(PPE) is sometimes the most practical means of prevent-

ing infectious disease transmission.

The CDC guideline

states that the use of standard pre-

cautions is based on the principle that all blood, body flu-

ids, secretions, excretions (except sweat), nonintact skin,

and mucous membranes may contain transmissible infec-

tious agents. These precautions include infection preven-

tion practices that apply to all patients and all settings in

which health care is delivered. Prevention practices

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

include hand hygiene; use of gloves, gown, respirators,

masks, eye protection, or face shield, depending on the

anticipated exposure; and safe injection practices.

Hand hygiene is often noted as the most important prac-

tice to reduce the transmission of infectious agents in

health care settings as well as being an essential compo-

nent of standard precautions.

Hand hygiene includes

both hand-washing with either plain or antiseptic-

containing soap and water, and the use of alcohol-based

products (gels, rinses, foams) that do not require the use

of water.

Hand hygiene is a critical activity for health

care personnel, but it is also important for patients and

visitors. Extensive information on hand hygiene, includ-

ing resources and tools, is provided in the publication

Measuring Hand Hygiene Adherence: Overcoming the

Challenges (see Resources 3-4, page 87).

Using physical barriers and PPE protects workers and patients

from exposure and possible disease transmission. Examples of

PPE as mentioned previously include gowns, respirators, gog-

gles, masks, and face shields. Recommendations for the appli-

cation of standard precautions for the care of all patients in all

health care settings is provided in Table 3-3, page 85. An inter-

active web-based educational program designed to promote

safer and more healthful hospitals by reducing occupational

transmission of infectious disease is available at http://innova-

tion.ghrp.ubc.ca/ProtectPatti/eng/.

A robust infection preven-

tion and control program is built on coordination between

occupational and infection preventionists and deploys multiple

strategies within a hierarchy of controls.

3.3 Exposure to Hazardous

Substances

3.3.1 Hazardous Drugs, Chemicals,

and Other Substances

By their nature, many treatment and diagnostic modalities

used in the health care setting place workers and others at

risk for unintended exposure to hazardous substances.

Medical interventions ranging from treatments involving

antineoplastic agents to radiographic diagnostics can place

staff and patients at risk for potential adverse health out-

comes. One of the most significant risks involves hazardous

drugs, identified by the NIOSH as including drugs used for

cancer chemotherapy, antiviral drugs, hormones, some bio-

engineered drugs, and other miscellaneous drugs.

In addi-

tion to antineoplastic drugs employed in patient treatment,

radiation used in diagnostic imaging and therapies may

expose the patient, health care workers, and others to serious

harm.

62,63

A variety of other physical and chemical agents used in the

health care facility, such as cleaning products, disinfectants,

sterilants, and anesthetic gases may also pose a health haz-

ard. For example, the use of bleach is increasing to prevent

Clostridium difficile infections; however, adverse reactions

have been reported among cleaning service workers.

When

present, hazardous materials can potentially expose patients

and health care workers to harm; therefore, this issue bene-

fits from a unified safety effort. The scope of this mono-

graph precludes addressing all of the potential hazardous

substances used in health care. For additional information,

readers are referred to Chapter 15 of the NIOSH State of

the Sector document (Chemicals and Other Hazardous

Exposures).

Two examples of hazardous substances found in

health care presented in this discussion are chemotherapeu-

tic drugs and exposure to medical radiation.

One of the first uses of a hazardous chemical for therapeutic

purposes occurred after nitrogen mustard, a chemical

weapon used in World War I, was observed to cause bone

marrow and lymph tissue regression in exposed soldiers.

Nitrogen mustard was then used as a treatment for lym-

phoid malignancies in what many consider to be the first

instance of cancer chemotherapy. This was followed by the

development of a family of drugs used for the treatment of

cancers. Hazardous drugs also include those used in HIV

therapy and antiviral agents. These drugs have been shown

in studies with humans and animals to have a “potential for

causing cancer, reproductive toxicity, birth defects, or acute

harm to health.”

NIOSH has developed and maintained a

List of Antineoplastic and Other Hazardous Drugs in

Healthcare Settings that is available at http://www.cdc.gov

/niosh/docs/2012-150/pdfs/2012-150.pdf.

In April 2011,

a letter jointly authored by OSHA, The Joint Commission,

and NIOSH informed health care organizations of recent

updates to the list and the need for health care organization

leadership to ensure that hazardous drug and safe handling

policies were in place.

The methods of exposure may include inhalation, skin con-

tact, skin absorption, ingestion (from hand to mouth), and

injection (needlestick or sharps injury). In 1986, following

early inquiries, OSHA published guidelines for the manage-

ment of antineoplastic drugs in the workplace.

The guide-

lines have been followed by additional guidelines, standards,

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

Table 3-3: Recommendations for the Application of Standard Precautions

for the Care of All Patients in All Health Care Settings

COMPONENT RECOMMENDATIONS

Hand hygiene After touching blood, body fluids, secretions, excretions, contaminated items; immediately after

removing gloves; between patient contacts

Personal Protective Equipment (PPE)

Gloves For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous

membranes and nonintact skin

Gown During procedures and patient-care activities when contact of clothing/exposed skin with

blood/body fluids, secretions, and excretions is anticipated

Mask, eye protection

(goggles), face shield*

During procedures and patient-care activities likely to generate splashes or sprays of blood, body

fluids, secretions—especially suctioning, endotracheal intubation

Soiled patient-care

equipment

Handle in a manner that prevents transfer of microorganisms to others and to the environment;

wear gloves if visibly contaminated; perform hand hygiene

Environmental control Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, espe-

cially frequently touched surfaces in patient-care areas

Textiles and laundry Handle in a manner that prevents transfer of microorganisms to others and to the environment

Needles and other sharps Do not recap, bend, break, or hand-manipulate used needles; if recapping is required, use a one-

handed scoop technique only; use safety features when available; place used sharps in puncture-

resistant container

Patient resuscitation Use mouthpiece, resuscitation bag, other ventilation devices to prevent contact with mouth and

oral secretions

Patient placement Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contami-

nate the environment, does not maintain appropriate hygiene, or is at increased risk of acquiring

infection or developing adverse outcome following infection

Respiratory hygiene/

cough etiquette

(source containment of

infectious respiratory

secretions in symptomatic

patients, beginning at ini-

tial point of encounter, for

example, triage and

reception areas in emer-

gency departments and

physician offices)

Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and dis-

pose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secre-

tions; wear surgical mask if tolerated or maintain spatial separation greater than 3 feet if possible

* During aerosol-generating procedures on patients with suspected or proven infections transmitted by respiratory aerosols (such as SARS),

wear a fit-tested N95 or higher respirator in addition to gloves, gown, and face/eye protection.

Source: Siegel JD, Rhinehart E, Jackson M, Chiarello L. Health Care Infection Control Practices Advisory Committee. 2007 Guideline for

Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. 2007 Dec;35(10 Suppl

2):S65–164. PubMed PMID: 18068815.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Resources 3-4: Prevent Infection Transmission

Title and Website Description

Agency for Healthcare Research and Quality (AHRQ)

Toolkit

AHRQ Quality Indicators™ Toolkit for Hospitals. Improving

Performance on the AHRQ Quality Indicators

http://www.ahrq.gov/qual/qitoolkit/d7_implementationmeasurement

.docx

The toolkit is designed to help your hospital under-

stand the Quality Indicators (QIs) from the Agency for

Healthcare Research and Quality (AHRQ) and sup-

port your use of them to successfully improve quality

and patient safety. It includes a section on infection

prevention.

Association for Professionals in Infection Control and Epidemiology (APIC)

Practice Resources

http://www.apic.org/Professional-Practice/Practice-Resources

This link directs the reader to APIC’s Professional

Practice Resources Page.

Centers for Disease Control and Prevention (CDC)

Guidelines

2007 Guideline for Isolation Precautions: Preventing Transmission of

Infectious Agents in Healthcare Settings

http://www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf

This guideline updates and expands the 1996

Guideline for Isolation Precautions in Hospitals.

Intended for use by infection control staff, health care

epidemiologists, health care administrators, nurses,

other health care providers, and persons responsible

for developing, implementing, and evaluating infec-

tion control programs for health care settings across

the continuum of care. The reader is referred to other

guidelines and websites for more detailed information

and for recommendations concerning specialized

infection control problems.

Information on HAI Topics

Healthcare–Associated Infections (HAIs)

http://www.cdc.gov/hai/

This site directs the reader to information on multiple

topics including incidence, organisms, prevention,

and research.

Tools

Personal Protective Equipment

http://cdc.gov/HAI/prevent/ppe.html

Tools related to use of PPE for protecting health care

personnel and patients from exposure to microbiolog-

ical hazards include videos, slides, and posters.

Institute for Healthcare Improvement (IHI)

Improvement Map

http://app.ihi.org/imap/tool/

This website provides a customized collection of

processes to guide improvement efforts in preventing

HAIs.

Joint Occupational Health & Safety Committee (Canadian Centre for Occupational Health & Safety)

Resource Tool

Protect Patti

http://innovation.ghrp.ubc.ca/ProtectPatti/eng/

This website, developed by the University of British

Columbia, includes an interactive learning tool to pro-

mote safer and more healthful hospitals by reducing

occupational transmission of infectious diseases.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

Resources 3-4: Prevent Infection Transmission (continued)

Title and Website Description

National Quality Forum (NQF)

Report

Safe Practices for Better Healthcare 2010 Update: A Consensus

Report. Abridged report. Washington, DC 2010 (accessed 11/21/11)

http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for

_Better_Healthcare_%e2%80%93_2010_Update.aspx

This is a report comprising 34 practices that have

been demonstrated to be effective in reducing the

occurrence of adverse health care events. Chapter 7

is focused on the prevention of HAIs.

Occupational Safety and Health Administration (OSHA)

Standards Related to Healthcare

http://www.osha.gov/SLTC/healthcarefacilities/standards.html

This link provides OSHA standards, directives, and

standard interpretations related to health care.

Society for Healthcare Epidemiology of America (SHEA)

Guidelines

A Compendium of Strategies to Prevent Healthcare-Associated

Infections in Acute Care Hospitals

http://www.shea-online.org/GuidelinesResources/Compendiumof

StrategiestoPreventHAIs.aspx

This document presents a summary of the guidelines

to prevent HAIs in acute care hospitals. Also pre-

sented are practical recommendations in a concise

format designed to assist acute care hospitals in

implementing and prioritizing their HAI prevention

efforts. Four device and procedure-associated HAI

categories are targeted as well as two organism-

specific HAI categories.

The Joint Commission

Monograph

Measuring Hand Hygiene Adherence: Overcoming the Challenges

http://www.jointcommission.org/Measuring_Hand_Hygiene_Adherence

_Overcoming_the_Challenges_/

This monograph provides a framework to help health

care workers make necessary decisions about what,

when, why, and how they will measure hand hygiene

performance. It includes examples of tools and

resources to help organizations select the measure-

ment approaches that best fit their needs.

Monograph

Providing a Safer Environment for Health Care Personnel and

Patients through Influenza Vaccination

http://www.jointcommission.org/Providing_a_Safer_Environment/

This monograph provides information to help health

care organizations of all types improve seasonal

influenza vaccination rates in health care personnel.

Monograph

Preventing Central Line–Associated Infections: A Global Challenge,

A Global Perspective

http://www.jointcommission.org/preventing_clabsi/

This monograph contains the most current informa-

tion, evidence-based guidance, and resources to

assist healthcare organizations in reducing central

line–associated bloodstream infections (CLABSIs).

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

and recommendations (see Resources 3-5, page 92, for

examples). Health care workers at particular risk for adverse

outcomes from exposure include pharmacists, pharmacy

technicians, nursing personnel, physicians, operating room

staff, and auxiliary staff in shipping/receiving, waste han-

dlers, and maintenance workers.

Because contamination of

work surfaces from these drugs has been found in patient

treatment areas,

2,61

family members and caregivers are poten-

tially at risk for second-hand exposure.

Although adminis-

tration of these drugs initially was always performed in the

hospital, many treatments are now performed in the outpa-

tient setting. For example, data from 2007 shows that of the

approximately 23 million annual adult patient visits for

chemotherapy, 19 million (84%) were conducted in ambu-

latory care settings.

Across all settings, there is no consis-

tent regulatory framework or mandatory, standardized

requirements for risk-mitigation interventions. Current reg-

ulations covering hazardous drugs involve multiple agencies,

such as OSHA, the Department of Transportation, and the

Environmental Protection Agency. Recommendations and

guidelines for working with hazardous drugs have been

developed by federal agencies and professional societies.

61,71–73

3.3.1.1 Impact on Patients and Workers

In the United States an estimated 8 million health care

workers are involved in some part of the process of haz-

ardous drug preparation, administration, or disposal,

thereby risking exposure.

Reports of symptoms following

occupational exposure to hazardous drugs include immedi-

ate nervous system effects, skin rashes, sore throat, dizziness,

headache, allergic reaction, diarrhea, nausea, and vomit-

ing.

70,73

Cancer and adverse reproductive outcomes, such as

birth defects, low birth weight, fetal loss, and infertility,

have been found in studies of exposed workers.

75–77

A recent

study of 7,500 nurses who had a pregnancy between 1993

and 2002 found that about 2 out of 10 nurses who had

handled chemotherapy drugs for more than an hour a day

had a miscarriage compared to 1 in 10 overall.

Multiple

factors influence occupational exposures, including the

following:

• Drug handling circumstances (compounding, adminis-

tration, or disposal)

• Amount of drug prepared

• Frequency and duration of drug handling

• Potential for absorption

• Use of biological safety cabinets or other ventilated

cabinets

• Use and adequacy of PPE

• Work practices

Although the toxic effects of hazardous drugs used in vari-

ous medical therapies are also observed in patients receiving

them, the potential therapeutic benefits outweigh the risks

of side effects.

3.3.1.2 Safe Drug Handling Examples

Organizations are encouraged to develop a comprehensive

safe handling program for hazardous drugs. A listing of the

Resources 3-4: Prevent Infection Transmission (continued)

Title and Website Description

The Joint Commission [continued]

Monograph

Tdap Vaccination Strategies for Adolescents and Adults, Including

Health Care Personnel: Strategies from Research and Practice

http://www.jointcommission.org/tdap/

This monograph incorporates evidence-based guide-

lines and published literature to highlight practical

strategies to improve Tdap (tetanus, diphtheria, and

pertussis) vaccination rates. Additionally, the mono-

graph includes examples of vaccination initiatives that

organizations have used to establish or enhance

Tdap vaccination programs.

Report, Issue 3: Requirement, Rationale, Reference

Influenza vaccination for licensed independent practitioners and staff

http://www.jointcommission.org/assets/1/18/R3_Report_Issue_3_5

_18_12_final.pdf

Report provides the rationale and references that

The Joint Commission employs in the development of

new requirements. While the standards manuals also

provide a rationale, the rationale provided in R

Report goes into more depth.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

NIOSH recommendations for safe handling of antineoplas-

tic and other hazardous drugs is provided in Table 3-4.

Some examples of interventions to promote safe drug han-

dling are shown in Sidebar 3-3, page 91.

3.3.1.3 Safe Disposal of Hazardous Drugs or

Waste

Care should also be taken when handling waste resulting

from hazardous drug preparation or administration. All

materials that come into contact with hazardous drugs or

waste from patients receiving therapy with hazardous drugs

(antineoplastics, radionuclides, etc.) can potentially contain

hazardous materials or their metabolites. They should be

treated as hazardous and should be handled in the same

manner as the parent material. Personnel collecting and

transporting these materials should take the appropriate pre-

cautions, such as wearing the recommended PPE and fol-

lowing the institution’s protocols. In addition, each facility

or institution should develop a policy for separation and safe

disposal of hazardous drug material. The NIOSH Alert (see

Resources 3-5, pages 92–93) also provides specific tips

regarding hazardous drug waste disposal.

3.3.1.4 Survey of Health Care Worker Extent

and Exposure to Hazardous Chemical

Agents

Results from a recently completed NIOSH Health and

Safety Practices Survey of Healthcare Workers promise to

provide important new information about health care work-

ers’ work experiences concerning use of hazardous chemi-

cals.

Twenty-one professional health care organizations

partnered with NIOSH and invited their members to partic-

ipate in the voluntary web-based survey. The purpose of the

survey was to better understand the extent and circumstances

of exposure to antineoplastic agents, anesthetic gases, surgical

smoke, high-level disinfectants, chemical sterilants, and

aerosolized medications. Information on the use of exposure

controls (and barriers to their use, if not used) was also col-

lected. Results are expected to be published in early 2013.

3.3.2 Radiation

Radiation is used in health care for diagnostic and therapeu-

tic purposes. X-rays are officially classified as a carcinogen

by WHO’s International Agency for Research on Cancer,

the CDC’s Agency for Toxic Substances and Disease

Registry, and by the NIH National Institute of

Environmental Health Sciences.

Identified risks related to

radiation exposure include burns, cancer, and other

injuries.

Like the drugs used in chemotherapy, radiation

places health care workers at risk for unintentional exposure,

whereas patients are at potential risk for adverse outcomes

related to dosage and frequency of exposure. New technol-

ogy has increased the availability and utilization of medical

imaging procedures, some of which require the clinician to

maintain close physical contact with the patient during radi-

ation exposure.

Increased use of diagnostic imaging in the

past two decades has almost doubled the total exposure to

ionizing radiation in the US population.

Dental radiogra-

phy also exposes patients and staff to low-dose ionizing radi-

ation, which may be associated with increased risk for

thyroid cancer, particularly with multiple exposures.

Findings of a recent congressional analysis reported in the

media found that patients with cancer and other diseases who

are being treated with radioactive materials, such as radioactive

iodide, can now choose to be released from the hospital to

their home or a hotel for recovery, potentially exposing family

and others to radiation.

Members of the population at great-

est risk of harm from exposure are pregnant women and

young children. Contamination of the patient’s environment

can include bedding, personal laundry, room surfaces, and so

on. Currently, regulations in the United States allow patients

treated with radioisotopes to be sent home, in contrast to

other countries where hospitalization is required for treat-

ment.

Protecting those individuals around the patient

depends heavily on educating the patient and family on risk

precautions and limiting exposure to vulnerable individuals.

3.3.2.1 Impact on Staff and Patients

Data gathered from studies of health care workers exposed

to radiation prior to 1950 show excess risk of leukemia, skin

cancer, and female breast cancer.

The introduction of risk-

mitigation procedures, such as lead aprons, increased worker

and patient safety. However, as noted previously, the devel-

opment of new and complex imaging technologies com-

bined with the increased utilization of medical imaging

requires new epidemiological studies to evaluate the impact

on patients and workers. While safety guidelines and federal

regulations require dose exposure monitoring for some

health care personnel working with radiation technologies,

more study is needed on the average annual, time-trend,

and organ doses from occupational radiation exposures, as

well as assessment of lifetime cancer risks for these workers.

Researchers have studied patient risk for development of

cancer due to diagnostic radiation exposure. For example,

one study estimated that 29,000 future cancers could

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Table 3-4: NIOSH Recommendations for Safe Handling of

Antineoplastic and Other Hazardous Drugs

Activity Recommendations

Receiving and storage of

drugs

Wear Personal Protective Equipment (PPE) suitable for task being performed

Properly label all hazardous drugs

Store and transport drugs in proper containers

Preparation and

administration of drugs

Evaluate drug preparation and administration policies

Wear suitable PPE, including double gloves for task being performed

Limit access to areas where drugs are prepared

Use proper engineering controls when preparing drugs

Wash hands with soap and water before donning and after removing gloves

Prime intravenous tubing in a ventilated cabinet

Use needleless or closed systems when preparing and administering drugs

Do not disconnect tubing from an intravenous bag containing a hazardous drug

Dispose of used materials in the appropriate container

Ventilated cabinets Perform all preparations with hazardous drugs in a ventilated cabinet designed to reduce

worker exposure

Do not use supplemental engineering controls as a substitute for a ventilated cabinet

When asepsis is required, select a cabinet designed for both hazardous drugs containment

and aseptic processing

Horizontal laminar-flow clean benches should not be used for preparation of hazardous drugs

Properly maintain engineering controls as required by the manufacturer

Routine cleaning, decontami-

nation, housekeeping, and

waste disposal

Use suitable PPE for the task being performed

Establish periodic cleaning routines for all work surfaces and equipment used where haz-

ardous drugs are prepared or administered

Consider used linen and patient waste to be contaminated with the drugs and/or their metabolites

Separate wastes according to institutional, state, and federal guidelines and regulations

Spill control Manage spills according to written policies and procedures

Locate spill kits in areas where exposures may occur

Adhere to OSHA respiratory protection program

Dispose of spill material in a hazardous chemical container

Medical surveillance Participate in medical surveillance programs at work, or see your private health care provider

if one does not exist

Medical surveillance should include the following:

• Reproductive and general health questionnaires

• Complete blood count and urinalysis

• Physical examination at time of employment and periodic health status questionnaire

review

• Follow-up for workers who have shown health changes

Adapted from source: Connor TH, McDiarmid MA. Preventing occupational exposures to antineoplastic drugs in health care settings. CA

Cancer J Clin. 2006 Nov-Dec;56(6):354-65. Review. PubMed PMID: 17135692.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

develop from the 72 million computerized tomography

(CT) scans performed in 2007 in the United States.

The

patients at higher risk for harm from diagnostic radiation

include pregnant women, children, young adults, and indi-

viduals with increased sensitivity due to metabolic condi-

tions (for example, diabetes mellitus, hyperthyroidism).

with health care workers, the cumulative effect and dosage

exposures impact the risk for each patient.

3.3.2.2 Examples of Interventions

The Image Gently program developed by the Society of

Pediatric Radiology targets safe imaging guidelines for

Sidebar 3-3: Examples of

Interventions to Promote Safe

Drug Handling

Administration – Management – Leadership

• Resources (financial and human) to implement a

comprehensive safe handling program.*

• Initial and periodic training.

†

• Policies and procedures that address areas such as

the following: storage, preparation, administration,

and disposal of drugs; prohibition of food and bever-

ages in preparation areas; use of PPE; hazardous-

spill management and cleanup; and workers’

hazardous drug handling during pregnancy or breast

feeding.

†‡

• Identification/communication of hazardous drugs used

and updates as new drugs are added (maintain a list

of drugs or electronically tag hazardous drugs in facil-

ity records systems, signage).*

†

• Limit employee access to preparation areas to those

involved in drug preparation.

†

Engineering – Equipment – Environment

• Use of biological safety cabinets (BSC) or compound-

ing aseptic containment isolators (CACI) and

approved ventilation for preparation areas.*

†§||

• Use of closed-system drug transfer devices.

†

• Use of closed IV systems/needleless systems.

†#

• Use of PPE (gowns, respirators, gloves).

†‡§

• Favorable practice environment (physical layout and

design of workspace).

†§||

• Proper use and maintenance of equipment.

†||

• Storage of hazardous drugs separate from other

drugs in areas with adequate ventilation to dilute and

remove any airborne contaminants.

†

• Environmental services management of waste,

housekeeping, laundry.

†||

Behaviors – Health Care Workers – Patients – Others

• Medical surveillance of all workers at risk of exposure

to hazardous drugs.

†||

††

– Physical examination at time of hire and repeated

as needed.

||††

– Initial laboratory tests such as a complete blood

count.

||††

– Employee completion of health questionnaires at

time of hire and periodically thereafter.

† ††

• Participate in training on handling hazardous drugs

and updates as new information becomes available.

†||

• Consistent use of recommended PPE.

†§††

• Washing hands after drug-handling activities and

removal of PPE.

†§||

• Adherence to guidelines for handling hazardous

drugs.

†§

• Adherence to policies and procedures for handling

hazardous drugs.

†

References:

* Massoomi FF, Neff B, Pick A, Danekas P. Implementation of

a safety program for handling hazardous drugs in a com-

munity hospital. Am J Health Syst Pharm. 2008 May

1;65(9):861-865.

† Department of Health and Human Services, Centers for

Disease Control and Prevention, National Institute for

Occupational Safety and Health [Internet]. Cincinnati (OH):

Department of Health and Human Services; [updated 2004

Sep; cited 2011 Aug 19]. Preventing Occupational Exposure

to Antineoplastic and Other Hazardous Drugs in Health

Care Settings; [about 58 p.].Available from:

http://www.cdc.gov/niosh/docs/2004-165/.

‡ Polovich M. Safe handling of hazardous drugs. Online J

Issues Nurs. 2004 Sep 30;9(3):6. Review. PubMed PMID:

15482092.

§ US Pharmacopeial Convention [2008]. Pharmaceutical

compounding sterile preparations. Chapter <797>. 31st ed.

Rockville, MD: United States Pharmacopeial Convention.

|| OSHA Technical Manual; Section VI, Chapter 2: Controlling

Occupational Exposure to Hazardous Drugs [OSHA 1999].

# American Society of Health-System Pharmacists (ASHP).

ASHP Guidelines on Handling Hazardous Drugs: Am J of

Health-Syst Pharm. 2006; 63:1172–1193.

** ONS 2011: Polovich M, Bolton DL, Eisenberg S, Glynn-

Tucker EM, Howard-Ruben J, McDiarmid MA, Power LA,

Smith CA. Safe handling of hazardous drugs. Oncol Nurs

Society. Second Edition. February 2011.

†† Department of Health and Human Services, Centers for

Disease Control and Prevention, National Institute for

Occupational Safety and Health [Internet]. Cincinnati (OH):

Department of Health and Human Services; c2007 [cited

2011 Oct 11; updated 2007 Apr]. Workplace Solutions:

Medical Surveillance for Health Care Workers Exposed to

Hazardous Drugs, DHHS (NIOSH) Publication Number

2007-117; [about 4 p.]. Available from: http://www.cdc.gov

/niosh/docs/wp-solutions/2007-117/.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Resources 3-5: Hazardous Drugs and Substances

Title and Website Description

American Society of Health System Pharmacists (ASHP)

Case Study

Implementation of a safety program for handling hazardous drugs in a

community hospital

http://www.ashp.org/DocLibrary/Policy/compounding/HD_Massoomi.aspx

A case study of a community hospital safe drug-

handling program

Guidelines on Handling Hazardous Drugs

http://www.ashp.org/DocLibrary/BestPractices/PrepGdlHazDrugs.aspx

The American Society of Health-System Pharmacists

(ASHP) is the membership organization that works

on behalf of pharmacists who practice in hospitals

and health systems

The primary goal of this document is to provide recom-

mendations for the safe handling of hazardous drugs

National Institute for Occupational Safety and Health (NIOSH)

Website

Hazardous Drug Exposures in Health Care

http://www.cdc.gov/niosh/topics/hazdrug/

Information on identifying hazards, determining

appropriate controls, and applying safe practices

regarding hazardous materials in health care settings

Publication

NIOSH Alert: Preventing Occupational Exposure to Antineoplastic and

Other Hazardous Drugs in Health Care Settings

http://www.cdc.gov/niosh/docs/2004-165/

Alert to increase awareness among health care work-

ers and their employers about the health risks posed

by working with hazardous drugs and to provide them

with measures for protecting their health

Publication

Medical Surveillance for Health Care Workers Exposed to Hazardous

Drugs

http://www.cdc.gov/niosh/topics/hazdrug/

Description of a medical surveillance program as part

of an organizational effort to minimize workplace

exposure to hazardous drugs; to be updated in late

2012

Publication

Personal Protective Equipment for Health Care Workers Who Work

with Hazardous Drugs

http://www.cdc.gov/niosh/docs/wp-solutions/2009-106/

NIOSH PPE recommendations for workers who han-

dle hazardous drugs in the workplace

Report

McDiarmid MA and Leone M.

Chapter 14: Hazardous Drugs

In: US Department of Health and Human Services, Centers for

Disease Control and Prevention, National Institute for Occupational

Safety and Health [Internet]. State of the Sector | Healthcare and

Social Assistance: Identification of Research Opportunities for the

Next Decade of NORA. DHHS (NIOSH) Publication Number 2009-

139. Available from: http://www.cdc.gov/niosh/docs/2009-139

This 236 page document, developed by the NORA

Healthcare and Social Assistance Sector Council,

addresses the "state of the sector," including magni-

tude and consequences of known and emerging

health and safety problems, critical research gaps,

and research needs that should be addressed over

the next decade of NORA. Chapter 14 discusses

hazardous drugs.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

Resources 3-5: Hazardous Drugs and Substances (continued)

Title and Website Description

National Institute for Occupational Safety and Health (NIOSH) [continued]

Listing

NIOSH List of Antineoplastic and Other Hazardous Drugs in

Healthcare Settings 2010

http://www.cdc.gov/niosh/docs/2010-167/

Updates the list of antineoplastic and other haz-

ardous drugs in earlier document, National Institute

for Occupational Safety and Health

NIOSH Alert: Preventing Occupational Exposures to

Antineoplastic and Other Hazardous Drugs in Health

Care Settings 2004

Occupational Safety and Health Administration (OSHA)

Hospital Training Tool

Hospital eTool

http://www.osha.gov/SLTC/etools/hospital/index.html

A stand-alone, interactive, Web-based training tool on

occupational safety and health topics. This eTool

focuses on some of the hazards and controls found

in the hospital setting, and describes standard

requirements as well as recommended safe work

practices for employee safety and health

Standards

Part 1910 – OSHA standards

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table

=STANDARDS&p_id=9696

Standards for health care facilities including haz-

ardous materials and PPE

Manual

OSHA Technical Manual (OTM)

Section VI: Chapter 2

Controlling Occupational Exposure to Hazardous Drugs

http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html

OSHA Compliance Safety and Health Officers

(CSHOs) use the OTM as a reference for technical

information on occupational safety and health issues

Hospital eTool

Healthcare Wide Hazards: Hazardous Chemicals

http://www.osha.gov/SLTC/etools/hospital/hazards/hazchem/haz.html

Website that covers a number of aspects of the hos-

pital setting in regards to hazardous drug handling

Oncology Nurses Society (ONS)

Publication

Safe Handling of Hazardous Drugs (Second Edition)

http://www.ons.org/ClinicalResources/SafeHandling

This publication includes information on procedures

needed to promote safety in the workplace. Information

on issues such as drug administration, management of

spills, and safety measures as well as details on the

adverse effects of hazardous drugs and evidence of

occupational hazardous drug exposure are included.

providing imaging radiation (and fluoroscopy) to the pedi-

atric patient.

Similarly, the Image Wisely program from the

American College of Radiology and the Radiological Society

of North America in collaboration with the American

Society of Radiologic Technologists, provides imaging guide-

lines for adult patients.

Multiple federal agencies provide

oversight and regulation in the area of medical devices that

emit radiation. For example, the Food and Drug

Administration (FDA) must be notified of any medical

device–related incident that results in the death of a staff

member or the hospitalization of three or more staff mem-

bers.

The FDA also oversees the MedWatch program (a

safety and adverse event reporting program) and the Center

for Devices and Radiological Health addresses the safety and

effectiveness of medical devices.

As with all risks in the

health care setting, a safety culture that holds safety as a core

organization value and focus will further promote safety in

medical radiation applications.

In August 2011, The Joint Commission issued a Sentinel

Event Alert on the radiation risks of diagnostic imaging.

The alert highlights contributing factors to sentinel events

and actions that health care organizations can take to help

eliminate avoidable radiation doses. Contributing factors

to, and activities that can help eliminate, avoidable radia-

tion doses include the following:

• Awareness of the potential dangers from diagnostic radi-

ation among organizational leadership, staff, and patients

• Development of a comprehensive patient safety pro-

gram, including education about dosing in imaging

departments

• Knowledge regarding typical doses

• Adequate awareness among physicians and other clini-

cians about the levels of radiation typically used and

related risks

87–90

• Training in the use of complex new technology

• Guidance in the appropriate use of potentially dangerous

procedures and equipment

• Adequately trained and competent staff

• Knowledge regarding typical doses

• Clear protocols that identify the maximum dose for each

type of study

• Consulting with a qualified medical physicist when

designing or altering scan protocols

• Communication among clinicians, medical physicists,

technologists, and staff

• Safety, operational, and functional checks of the equip-

ment before initial use and periodically thereafter

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Resources 3-5: Hazardous Drugs and Substances (continued)

Title and Website Description

Oncology Nurses Society (ONS) [continued]

Standards

ASCO/ONS Chemotherapy Safety standards

http://www.ons.org/Publications/Books/Excerpts/INPU0542toc

ONS and the American Society of Clinical Oncology

(ASCO) have collaborated to develop the first

national standards for the safe administration of

chemotherapy drugs, which was released in 2009

and focused on the adult population in the ambula-

tory setting. In 2011 a workgroup was convened to

review feedback and revise the safety standards as

needed. The scope has been extended to both the

outpatient and inpatient settings.

Washington State

Washington Department of Labor and Industries

Hazardous Drugs Rule

http://www.washingtonworkplacelaw.com/regulatory-compliance

/new-duties-for-health-care-facilities-to-protect-workers-against

-hazardous-drugs/

New duties for health care facilities to protect workers

against hazardous drugs

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

The Sentinel Event Alert further advises that organizations

can reduce risks related to avoidable diagnostic radiation

through raising staff and patient awareness of the increased

risks associated with cumulative doses and by providing the

following:

• The right test

• The right dose

• Effective processes

• Safe technology

• Safety culture

Additional information including specific action steps within

each of these areas is available from: http://www.joint

commission.org/sentinel_event.aspx, Issue 47, August 24,

2011.

3.4 Violence in the Health Care

Setting

3.4.1 Assault and Violence Prevention

and Management, Security

Violence in the workplace is not a new phenomenon.

However, over the past several years media coverage of inci-

dents ranging from shootings to physical assaults have

raised public awareness that health care settings are not

immune to workplace violence.

93–97

WHO defines violence

as “the intentional use of physical force or power, threat-

ened or actual, against oneself, another person, or against a

group or community that either results in or has a high

likelihood of resulting in injury, death, psychological harm,

mal-development or deprivation.”

Workplace violence has

been further defined by NIOSH as “violent acts (including

physical assaults and threats of assaults) directed toward per-

sons at work or on duty.”

Violence in the health care setting encompasses a range of

behaviors and actions from criminal assaults to intimidation.

Forms of intimidation can manifest as verbal (offensive or

threatening language) and psychological.

Sexual harassment

poses another threat to health care workers and to patients.

To recognize the potential risks and develop efficacious solu-

tions, the issues of violence and security call for an inte-

grated approach to safety planning for patients, health care

staff, visitors, and others. This section discusses a broad

spectrum of violent acts, both physical and nonphysical, as

well as how they might manifest and be addressed in the

varied settings in which health care services are delivered.

3.4.1.1 Impact on Patients and Workers

Physical Violence in the Health Care Workplace

The provision of health care services has traditionally been

associated with the acute care hospital. However, advances

in technology and changes in reimbursement have shifted

a large portion of service delivery to the patient’s home

and other outpatient venues. Specialty care such as behav-

ioral health services may be delivered in freestanding insti-

tutions. Care settings for the aged and cognitively

impaired include skilled and nonskilled care facilities as

well as assisted living. Each of these health care settings

share common issues as well as having unique challenges

and safety risks for staff and patients.

Hospitals

The hospital setting presents an array of risks for violence

impacting staff and patients. Recognized high-impact

areas include the emergency department, psychiatric unit,

and waiting rooms.

In addition to staff and patients,

hospitals are open to access by visitors, physicians, deliv-

ery personnel, and other members of the public. Hospitals

also have multiple security sensitive areas, including the

newborn nursery unit, pharmacy, and patient record

storage.

100

Hospitals are increasingly experiencing active threats. An

active threat is a situation that occurs without warning,

quickly degenerates, and has the potential to cause death

or serious injury.

101

Active threats such as an armed

attacker place everyone at risk but are less common than

other forms of violence. Disruptive behavior and assaults

by patients against staff and other patients is a far more

significant problem for most health care organizations

than the armed intruder. Data from the BLS for 1999

indicate that hospital workers had a rate of nonfatal

assaults of 8.3 per 10,000 workers—far higher than the

rate for private-sector industries of 2 per 10,000 work-

ers.

While staff is usually at greatest risk when a patient

becomes violent, other patients can also be targeted, as

occurred in 2008 when a patient noted to be angry and

anxious on admission awoke the following morning and

began punching his roommate in the face.

102

As noted pre-

viously, patient care areas at greater risk for violence

include emergency rooms, waiting rooms, mental health

units, and units for cognitively impaired.

2,100,103,104

Nurses

are a primary target for violence although physicians,

other staff, and patients can also be impacted. Types of

violent interactions identified by nurses include physical

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Resources 3-6: Radiation

Title and Website Description

American College of Radiology (ACR), the Radiological Society of North America (RSNA)

Initiative

A collaborative initiative of the American College of Radiology (ACR),

the Radiological Society of North America (RSNA), the American

Society of Radiologic Technologists (ASRT), and the American

Association of Physicists in Medicine (AAPM)

Image Wisely

http://www.imagewisely.org

The initiative aims to optimize the use of radiation in

adult medical imaging and to ensure that patients

receive only necessary scans. Radiologists, medical

physicists, and radiologic technologists are encour-

aged to visit imagewisely.org where they can take the

pledge to Image Wisely.

Publication

Appropriateness Criteria

http://www.acr.org/Quality-Safety/Appropriateness-Criteria/About-AC

The American College of Radiology states that the

criteria are evidence-based guidelines to assist refer-

ring physicians and other providers in making the

most appropriate imaging or treatment decision for a

specific clinical condition. By employing these guide-

lines, providers enhance quality of care and con-

tribute to the most efficacious use of radiology.

National Institute for Occupational Safety and Health (NIOSH)

Report

Condon M, Chen L, and Weissman D.

Chapter 15: Chemical and Other Hazardous Exposures

In: US Department of Health and Human Services, Centers for

Disease Control and Prevention, National Institute for Occupational

Safety and Health [Internet]. State of the Sector | Healthcare and

Social Assistance: Identification of Research Opportunities for the

Next Decade of NORA. DHHS (NIOSH) Publication Number 2009-

139. Available from: http://www.cdc.gov/niosh/docs/2009-139

This 236-page document, developed by the NORA

Healthcare and Social Assistance Sector Council,

addresses the "state of the sector," including magni-

tude and consequences of known and emerging

health and safety problems, critical research gaps,

and research needs that should be addressed over

the next decade of NORA. Chapter 15 discusses

chemical and other hazardous exposures.

The Alliance for Radiation Safety in Pediatric Imaging

Initiative

Image Gently

http://www.imagegently.org

Founding agencies of the alliance include: The Society for Pediatric

Radiology, American Association of Physicists in Medicine, American

College of Radiology, and American Society of Radiologic

Technologists

The Image Gently campaign is an initiative of the

Alliance for Radiation Safety in Pediatric Imaging.

The campaign goal is to change practice by increas-

ing awareness of the opportunities to promote radia-

tion protection in the imaging of children.

The Joint Commission

Sentinel Event Alert

Issue 47

Radiation Risks of Diagnostic Imaging

http://www.jointcommission.org/sea_issue_47/

Alert describing the risks of unintended radiation

exposure related to diagnostic imaging as well as

suggested steps to prevent occurrences in the future.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

assault; verbal attack, including swearing or threat-mak-

ing; and unwanted physical contact.

105

In several studies,

the percentage of emergency room nurses reporting

assaults or being victims of violence ranged from

8–67%.

106,107

This number may seem alarming, but in fact,

the real numbers are probably even higher. Many health

care staff, especially those working in high-risk units, do

not report assaults,

108

sometimes expressing the belief that

it is an unavoidable part of the job.

109,110

Protecting staff

and patients from active threats is a critical responsibility

for management of health care institutions.

Home Care

Home care represents one of the fastest growing segments

of health care services. The home care setting possesses

some of the same risks for violence found in the hospital

setting but also presents others unique to the community

environment. For example, staff may be working alone in

high risk districts with known criminal or gang-related

activity. The presence of other household members,

firearms, animals, and illicit drugs may present additional

safety risks.

111,112

Night visits, lack of safety training, and

failure to provide security escorts also increase the risks

for home health workers. Most significantly, the security

of the client’s home and the community environment are

not under the control of the home care agency, thus elim-

inating prevention options available in the institutional

setting (see Sidebar 3-5, page 98).

Recent research has suggested that staff and patient safety in

home health care are linked.

113

It has been observed that

staff response to safety risks may impact service delivery by

causing visits to be shortened, avoided, or even cancelled,

thereby affecting quality of and access to care.

111

Other Care Settings

Risks for violence are noted to be high in facilities providing

residential care and treatment for the aged, cognitively

impaired, and mentally ill. In fact, all types of aggressive

behaviors, including nonfatal physical and verbal assaults,

occur in this care setting.

114

Nursing assistants and support staff are often the target for

these attacks. A national survey conducted in 2004 of nurs-

ing assistants working in nursing homes found that 34% of

respondents reported having experienced physical injuries

resulting from resident assaults in the previous year.

115

The

survey further noted that factors associated with assault-

related injury included mandatory overtime and insufficient

time to assist residents with their activities of daily living.

Residents with behavioral and psychiatric disturbances pose

greater risks for violent acts.

Bullying, Harassment, and Disruptive Behaviors Among

Health Care Professionals

The health care workplace is a complex environment in

which a variety of professionals interact with each other as

well as patients, families, students in health care disciplines,

and others. As the health care work environment has come

under more scrutiny, attention has been drawn to the preva-

lence and impact of disruptive behaviors among health care

professionals.

Sidebar 3-4: What Are the Risk

Factors for Violence?

The risk factors for violence vary across settings

depending on location, size, and type of care. Common

risk factors include the following:

• Staff work practices

– Working alone

– Working when understaffed—especially during

meal times and visiting hours

– Transporting patients

• Environmental factors

– Long waits for service

– Overcrowded, uncomfortable waiting rooms

– Poor environmental design

– Inadequate security

– Unrestricted movement of the public

– Poorly lit corridors, rooms, parking lots, and other

areas

– Lack of staff training and policies for preventing

and managing crises with potentially volatile

patients

• Patient population factors

– Working directly with volatile people, especially if

they are under the influence of drugs or alcohol or

have a history of violence or certain psychotic

diagnosis

– Access to firearms

Adapted from source: Department of Health and Human

Services, Centers for Disease Control and Prevention, National

Institute for Occupational Safety and Health [Internet]. Cincinnati

(OH): Department of Health and Human Services; c2002 [updated

2002 Apr; cited 2012 Jan 31]. Violence: Occupational Hazards in

Hospitals, DHHS (NIOSH) Publication No. 2002-101; [about 15

p.]. Available from: http://www.cdc.gov/niosh/docs/2002-101/.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

A range of behaviors, from bullying to harassment to what is

termed “horizontal” or “lateral” violence are included (see

Glossary, page 140 for a full description of included behav-

iors). In a review of the research, Vessey et al.

116

noted that

bullying differed from horizontal violence “in that a real or

perceived power differential between the instigator and

recipient must be present in bullying, while horizontal vio-

lence occurs among peers.”

116,(p.136)

However, they also noted

that all of these terms are used interchangeably in the litera-

ture. For the purposes of their review, the authors defined

bullying, harassment, and horizontal violence (BHHV) col-

lectively as “repeated, offensive, abusive, intimidating, or

insulting behavior, abuse of power, or unfair sanctions that

makes recipients upset and feel humiliated, vulnerable, or

threatened, creating stress and undermining their self-

confidence.”

116,(p.136)

Nursing is frequently the professional group identified as

victims and perpetrators of horizontal violence. Nurses,

especially those who have recently graduated or are new to

the unit, can often be targeted.

117

In addition, the histori-

cal role of nurses in a hierarchical organization has often

placed them in vulnerable positions. However, this type of

violence is not limited to nurses. It has been reported

across many other health care team members, including

pharmacists, therapists, nursing assistants, and support

staff.

116,118

The dynamic nature of health care and the unique cul-

tural environment contribute to the climate in which dis-

ruptive behaviors can occur. Specifically, working in high

stress and emotional situations, often under staffing con-

straints and compounded by factors such as fatigue, are

contributing risk factors.

118

The impact of disruptive

behaviors in the workplace on staff and patients is not

insignificant. The workplace can become an unhealthy

and even hostile environment, increasing the risk to the

organization for litigation from both employees and

patients.

118

Vessey et al.

116

noted that the literature docu-

ments a range of responses in staff who are victims of hor-

izontal violence, including, but not limited to, stress,

avoidance and withdrawal behaviors, physical symptoms

from sleep disorders to headaches, anxiety, depression, and

loss of confidence and self-esteem. The reviewed research

further demonstrated that victimized nurses experienced

decreased self-confidence and competence; potentially

influencing the quality of nursing care provided and sub-

sequently patient care outcomes. Respondents to a 2004

survey by The Institute for Safe Medication Practices

Sidebar 3-5: Risks for Violence in

Home Visits

The risk for violence in home health care is influenced

by many factors and will vary by the geographic location,

types of services provided, and agency resources. In

one study to develop and test three measures for

assessing the risk of violence toward staff making home

visits, the following risk factors were identified:

• A household where someone has a prior history of

violent behavior

• A visit in which either the client/patient or household

members are under the influence of alcohol or illicit

drugs

• A visit to any household where someone is dually

diagnosed with a substance abuse disorder and a

mental illness

• A visit providing personal care to a client with a cogni-

tive impairment

• A household where lethal weapons (such as guns)

are not locked up

• The status of the risk factors is unknown.

Source: McPhaul K, Lipscomb J, Johnson J. Assessing risk for

violence on home health visits. Home Healthc Nurse. 2010

May;28(5):278–289. Used with permission.

Sidebar 3-6: Examples of

Disruptive Behaviors

• Targeting individuals for mistreatment

• Belittling or denigrating someone’s opinion

• Using condescending language and attitude

• Engaging in patronizing nonverbal communications,

such as eye rolling, raised eyebrows, smirking, and

so on

• Refusing to answer legitimate questions

• Incessantly criticizing, finding fault, and scapegoating

• Displaying an attitude of superiority regarding

another’s knowledge, experience, and/or skills

• Undermining the effectiveness of a person or team

• Spreading rumors and making false accusations

• Putting staff members in conflict with each other

• Engaging in tantrums and angry outbursts

• Engaging in unnecessary disruption

• Assaulting a fellow employee

Adapted from source: The Joint Commission. Putting the

Brakes on Health Care “Road Rage.” Environment of Care

News. Oak Brook (IL): Joint Commission Resources; 2010 Jan

[cited 2012 Jan 30];13(1):[about 3 p.].

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

noted that a previous experience of verbal abuse when

contacting a physician to question or clarify an order had

influenced a future decision to question a medication

order.

119

The compromise to communications critical to

safe patient care caused by disruptive behaviors between

team members increases the risk for errors and adverse

events. It also impacts the health and well being of health

care professionals, whether they are the direct target or an

observing bystander.

3.4.1.2 Examples of Interventions

As discussed in the preceding paragraphs, the types of vio-

lence and the multiple settings in which health care services

are provided present unique challenges to planning preven-

tive strategies. Successful violence prevention must begin

with a safety vision championed by organizational leadership

and supported by resources across departments and profes-

sional disciplines. It should also include patient concerns. In

1996 OSHA issued guidelines for preventing workplace vio-

lence in health care that could be applied to reduce risks

across settings and are applicable to a wide range of health

care workers. (See Sidebar 3-8.) In combination with other

industry standards and regulations addressing patient safety,

health care organizations can use these resources to develop

a violence prevention program that meets the needs of staff

and patients.

Criminal Acts and Active Threats

Managing the risk for serious—even criminal—violent

events requires multiple approaches. The advent of the 2001

terrorist attack on the United States raised a new level of

awareness for the potential risks intrinsic to public places

such as airports and high-impact targets such as nuclear

power plants. The potential for criminal activity or other

active threats requires assessing the entire physical plant’s

security for the protection of patients and staff alike.

Side Bar 3-7: Factors

Contributing to Behaviors that

Undermine a Culture of Safety

• High-stress environments

• High patient acuity

• Increased productivity demands

• Cost-containment requirements

• Embedded hierarchies

• Daily changes in shifts, rotations, and support staff

Source: The Joint Commission [Internet]. Oakbrook Terrace

(IL): The Joint Commission: c2012 [updated 2008 Jul 9; cited

2012 Jan 30]. Sentinel Event Alert, Issue 40: Behaviors that

undermine a culture of safety; [about 3 p.]. Available from:

http://www.jointcommission.org/sentinel_event_alert_issue_40

_behaviors_that_undermine_a_culture_of_safety/.

Sidebar 3-8: Elements for

Developing a Violence

Prevention Program in Health

Care Organizations

1. Management commitment must be evident in the

form of high level management involvement and sup-

port for a written workplace violence prevention policy

and implementation.

2. Meaningful employee involvement in policy devel-

opment, joint management-worker violence prevention

committees, post-assault counseling and debriefing,

and follow-up are all critical program components.

3. Worksite analysis includes regular walk-through sur-

veys of all patient care areas and the collection and

review of all reports of worker assault. A successful

job hazard analysis must include strategies and poli-

cies for encouraging the reporting of all incidents of

workplace violence, including verbal threats that do

not result in physical injury.

4. Hazard prevention and control includes the installa-

tion and maintenance of alarm systems in high risk

areas. It may also involve the training and posting of

security personnel in emergency departments.

Adequate staffing is an essential hazard prevention

measure, as is adequate lighting and control of

access to staff offices and secluded work areas.

5. Training and education must include preplacement

and periodic, educationally appropriate training

regarding the risk factors for violence in the health

care environment and control measures available to

prevent violent incidents. Training should include skills

in aggressive behavior identification and manage-

ment, especially for staff working in the mental health

and emergency departments.

Adapted from source: US Department of Labor. Occupational

Safety and Health Administration [Internet]. Washington (DC);

[updated 1996; cited 2012 Jan 30]. Guidelines for Preventing

Workplace Violence for Health Care & Social Service Workers,

OSHA 3148; [about 15 p.]. Available from: http://www.osha.gov

/Publications/OSHA3148/osha3148.html.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Until recently, public awareness of serious, even fatal, physi-

cal assaults in the health care workplace has been limited.

But today, publicized shootings and acts of violence in

health care settings have raised a new awareness that no

workplace—even a hospital—is immune from these dan-

gers. Furthermore, data suggests that the incidence of vio-

lence in health care is increasing.

120

Security—Institutional Setting

Hospitals in particular are at risk for criminal activity such

as violent acts by individuals, kidnapping, and theft of

patient data, pharmacologic or radiologic agents, and other

sensitive materials. Therefore, providing for the security of

the physical environment is an important element of pro-

tecting patients and workers. The importance of securing

the structures in which health care services are provided can-

not be overstated and can present significant challenges

when the public and multiple care providers and staff access

these facilities around the clock.

100

Organizations should

begin with a thorough assessment of building security, as

noted above. Special attention should be paid to high risk

areas such as the emergency department, where there is a

large volume of traffic and high stress levels.

100

Access to sen-

sitive areas including pharmacy, lab and x-ray, medical

records, and the mother-baby unit requires additional levels

of security.

Building Design

Building new or remodeling existing health care facilities

is an opportunity to integrate functions of safety and

security into the building structure and design. Emerging

evidence-based design solutions are supporting construc-

tion of facilities that maximize patient care delivery in

environments that are not only secure but also promote

patient and worker well-being. Planning a safer health

care facility is enhanced by integrating architectural

design and the needs of patients, families, and health care

professionals.

121

Controlling Access

Examples of traditional approaches to controlling access

include physical barriers, such as door locks and fences,

combined with special lighting, cameras, and security

guards. Sophisticated electronic security systems using

technology such as key card entry and user recognition are

increasingly being deployed. This allows for selectively

controlling access only by approved individuals. But these

systems can be expensive and may create a false sense of

security when used as the sole solution. Technology alone

will not fully provide effective facility security. It must be

combined with comprehensive employee training.

In a review of the Joint Commission’s Sentinel Event

Database from 2004 to 2009, the following contributing

causal factors regarding criminal events in health care organ-

izations were identified most frequently

100

• Leadership, noted in 62% of the events, most notably

problems in the areas of policy and procedure develop-

ment and implementation.

• Human resources–related factors, noted in 60% of the

events, such as the increased need for staff education and

competency assessment processes.

• Assessment, noted in 58% of the events, particularly in

the areas of flawed patient observation protocols,

inadequate assessment tools, and lack of psychiatric

assessment.

• Communication failure, noted in 53% of the events,

among staff, patients, and families.

• Physical environment, noted in 36% of the events, in

terms of deficiencies in general environmental safety and

security practices.

• Problems in care planning, information management, and

patient education were causal factors identified less

frequently.

Preventing violence and enhancing security requires a multi-

pronged approach that includes defined and successfully

implemented policies and procedures, together with a well-

educated workforce that have practiced responding to

threatening situations. Finally, nothing can substitute for

alert employees who speak up. As noted by Russell Colling,

MS, CHPA:

“The most important factor in protecting patients

from harm is the caregiver—security is a people

action and requires staff taking responsibility, asking

questions, and reporting any and all threats or suspi-

cious events.”

100(p. 2)

A more extensive list of suggested actions to prevent vio-

lence in health care organizations can be found in the Joint

Commission Sentinel Event Alert Issue 45 (see Resources

3-7, page 104).

100

Security—Non-Institutional Settings

Institutional interventions cannot be fully duplicated in the

community workplace. Obvious limitations are related to

the lack of control over the physical structure in which serv-

100

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

ices are delivered, eliminating the options for building secu-

rity outlined previously. However, there are still interven-

tions that should be implemented to protect staff and

patients in the community setting.

Developing a safety program for the home care setting

involves including elements common to the institutional

setting, such as leadership; policies and procedures; staff

education and practice; and assessment of the patient, infor-

mal caregivers, and family members. It will also require

scrutiny of the physical environment—both in the home

and the immediate community—as well as elements unique

to the setting. Conducting thorough and ongoing assess-

ments of the hazards through surveillance will inform safety

program planning, resource allocation, and development of

risk prevention strategies. Staff education and training in

violence prevention and response to disruptive behavior is a

key element of a safety program. Involving the patient and

family in safety planning is also critical, as they control the

care environment and will be the ones to implement plans

suggested by the visiting health professional.

113

Home care

agencies can also provide services to staff, such as alarms,

cell phones, and security escorts. Communication mecha-

nisms to ensure that staff is informed of in-home threats

related to weapons, animals, substance abuse, mental illness,

and so on are key to safe visitation.

Violence Prevention—Disruptive Behavior

Methods to address disruptive behaviors displayed by

patients and families toward health care personnel differ

from those directed toward horizontal violence. While vio-

lent verbal outbursts by patients and families cannot always

be predicted, health care personnel can be attuned to signs of

increasing agitation. Anxiety connected with pain and fear,

compounded by long waiting periods and lack of informa-

tion, can become triggers of explosive behavior. Early inter-

vention, such as keeping patients and families informed, will

help control anxiety.

106

When disruptive behaviors do occur,

staff who have been educated in methods of de-escalating

these behaviors may be able to effectively calm the patient

and enhance care outcomes. Some programs have been

developed to improve management and care outcomes for

patients known to have a history of disruptive behavior (see

Case Study 3-6, page 108).

As noted previously, horizontal violence involves many

variables, both individual and organizational. All health

care organizations are encouraged to adopt policies to

indicate this behavior is unacceptable.

117,118

This policy

101

Sidebar 3-9: Strategies for

Managing Potentially Explosive

Behavior

• Ensure your personal safety. Assess your safety in

each situation, watch for warning signs, and don’t

ignore your feelings. Use simple, direct commands to

gain patient cooperation, and protect yourself by ask-

ing for assistance if necessary.

• Keep a colleague informed. Always tell a colleague

where you’re going and about how long you expect to

be with a patient.

• Assess the area: Inspect the patient surroundings for

items that might be used as weapons, stay at least

two arm lengths away from an agitated patient, and

don’t turn your back on an agitated patient.

• Create an exit: Be aware of where the exit is located

and don’t allow the patient to get between you and

the door.

• Direct bystanders away: For their own and the

patient’s protection and to prevent them from acciden-

tally getting in the way, ask bystanders to move away

from the area.

• Keep waiting areas separate: If possible, separate

patients, families, or others involved in a conflict to dif-

ferent waiting areas. If not possible, request additional

security personnel.

• Use verbal interventions: Use established tech-

niques and recommended verbal responses to de-

escalate agitation. Avoid arguing or using

inflammatory statements.

• Treat the patient with dignity and respect:

Communicate respect by listening carefully and

demonstrating nonaggressive, nonchallenging body

language.

• Offer choices: Give the patient and family a sense of

control by offering choices when appropriate.

• Help patients regain self-control: Ask patients what

would help them calm down or make them comfort-

able. Show them you are trying to meet their needs.

Source: Leckey DK. Ten strategies to extinguish potentially

explosive behavior. Nursing. 2011 Aug;41(8):55-59. Used with

permission.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

should be supported by defined strategies and enforce-

ment. Suggested areas for improvement include interdisci-

plinary collaboration, communication, and education and

training.

117

Organizations may wish to start by surveying

staff to gain an understanding of the prevalence and

nature of disruptive behaviors (a table describing five

instruments to measure constructs of disruptive

behavior is provided in Vessey et al., 2010, pages

148–149).

116

3.4.1.3 Case Studies

The following case studies address different aspects of vio-

lence prevention and security within various health care set-

tings. They present a range of interventions from the

development of a violence prevention program involving

patients and staff in a public hospital behavioral health facil-

ity, to a unique security system in a large multifacility health

system, to a behavioral management program for patients

with recurring episodes of disruptive behavior cared for in a

national health care system.

102

Resources 3-7: Assaults and Violence

Title and Website Description

American Association of Critical-Care Nurses

Position Statement

Zero Tolerance for Abuse (2004)

http://www.aacn.org/wd/practice/docs/publicpolicy/zero-tolerance-for

-abuse.pdf

Statement condemns acts of abuse perpetrated by or

against any person. It calls for a zero-tolerance

stance on any abuse and disrespect in the work-

place.

Position Statement

Workplace Violence Prevention (2004)

http://www.aacn.org/wd/practice/docs/publicpolicy/workplace

_violence.pdf

Statement condemns acts of violence perpetrated by

or against any person and calls upon health care

institutions to create organized programs to prevent

and combat workplace violence

American Nurses Association (ANA)

Resolution

Workplace Abuse and Harassment of Nurses (2006)

http://nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy

-Nurse/WorkplaceAbuseandHarassmentofNurses-1.pdf

Summary of proceedings of the American Nurses

Association 2006 House of Delegates on Abuse and

Harassment of Nurses in the Workplace.

Brochure

ANA Brochure: Preventing Workplace Violence

http://nursingworld.org/MainMenuCategories/WorkplaceSafety

/bullyingworkplaceviolence/PreventingWorkplaceViolence.pdf

Discusses three categories of risk factors: environ-

mental, work practices, and characteristics of victims

and perpetrator

Brochure

ANA Brochure: Your Health and Safety Rights

http://nursingworld.org/MainMenuCategories/WorkplaceSafety

/bullyingworkplaceviolence/YourHealthandSafetyRights.pdf

Discusses risk factors that can lead to workplace vio-

lence, and ways to prevent workplace violence and

take action if violence occurs

Web Site

http://nursingworld.org/MainMenuCategories/WorkplaceSafety

/bullyingworkplaceviolence

This site includes both complimentary informational

materials, and educational tools and courses for pur-

chase.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

103

Resources 3-7: Assaults and Violence (continued)

Title and Website Description

ECRI Institute

Publication

ECRI Institute [Internet]. Plymouth Meeting (PA): 2005 Sep [cited

2010 Mar 11]. Violence in Healthcare Facilities. Healthcare Risk

Control. Available from: https://www.ecri.org/Forms/Pages

/Violence_in_Healthcare_Facilities.aspx

Topics include techniques for identifying potentially

violent individuals, violence de-escalation tools that

health care workers can employ, violence manage-

ment training, conducting a violence audit, and

responding in the wake of a violent event

International Critical Incident Stress Foundation

Course

Assaulted Staff Action Program (ASAP)

Coping with the Psychological Aftermath of Violence

http://www.icisf.org

A course designed for staff in agencies where vio-

lence is a regular issue. ASAP is a Critical Incident

Stress Management intervention (CISM) to assist per-

sons who are victims of violence and/or who witness

violence happening to others.

International Association for Healthcare Security and Safety

Healthcare Security: Basic Industry Guidelines

http://www.iahss.org/About/Guidelines-Preview.asp

A resource for use in planning, developing, and man-

aging a security management plan, conducting secu-

rity training and investigations, identifying high risk

and more

National Institute for Occupational Safety and Health (NIOSH)

Fast Facts

Home Healthcare Workers

How to Prevent Violence on the Job

http://www.cdc.gov/niosh/docs/2012-118/

A fact sheet on risks in home care providing advice

for the employer and employee in preventing and

managing danger

Report

Palermo T and Hodgson MJ.

Chapter 13: Violence

In: US Department of Health and Human Services, Centers for

Disease Control and Prevention, National Institute for Occupational

Safety and Health [Internet]. State of the Sector | Healthcare and

Social Assistance: Identification of Research Opportunities for the

Next Decade of NORA. DHHS (NIOSH) Publication Number 2009-

139. Available from: http://www.cdc.gov/niosh/docs/2009-139

This 236-page document, developed by the NORA

Healthcare and Social Assistance Sector Council,

addresses the "state of the sector," including magni-

tude and consequences of known and emerging

health and safety problems, critical research gaps,

and research needs that should be addressed over

the next decade of NORA. Chapter 13 discusses

violence.

Article

Workplace Violence in the Healthcare Setting

http://search.medscape.com/viewarticle/749441

Dan Hartley, EdD, and Marilyn Ridenour, BSN, MBA, MPH

Examines three diverse data sets, each with a differ-

ent level of injury severity that provide information on

the prevalence of workplace violence and the need

for prevention strategies in all health care facilities

These authors are also developing a free online train-

ing course that should be available from CDC in 2012.

Website

Occupational Hazards in Hospitals

http://www.cdc.gov/niosh/topics/violence/

Provides links to NIOSH’s field studies and surveys,

as well as publications in occupational violence in

regard to risk factors and prevention strategies

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Lemuel Shattuck Hospital

Jamaica Plain, Massachusetts

The Violence Reduction Program

In response to a high rate of assaults resulting in injuries

by patients against other patients and staff, leadership for

the Metro Boston Mental Health Units (MBMHU) of the

Lemuel Shattuck public health hospital sought to create a

violence reduction program that combined existing best

practices and evidence-based practices in use at this and

other facilities. Founded in 1954, the hospital has 12 sto-

ries and 258 beds, with 143 medical beds on 4 floors and

115 behavioral health beds on 3 floors. Patients admitted

to behavioral health come primarily from three sources:

acute care hospitals (treatment has failed or patient pres-

ents a risk of violence to self or others); a correctional

state psychiatric facility; and the courts. The median

length of stay is approximately seven months. There are

five behavioral health units with 23 patients each, along

with limited on-site and extensive off-site rehabilitation

104

Resources 3-7: Assaults and Violence (continued)

Title and Website Description

National Institute for Occupational Safety and Health (NIOSH) [continued]

Publication

Workplace Violence Prevention Strategies and Research Needs

http://www.cdc.gov/niosh/docs/2006-144/

Provides a useful framework for thinking about the

current state of workplace violence research, preven-

tion, and communication activities in the United

States

Occupational Safety and Health Administration (OSHA)

Booklet

Guidelines for Preventing Workplace Violence for Health Care and

Social Service Workers (2004)

http://www.osha.gov/Publications/osha3148.pdf

Advisory guidelines intended to help employers

establish effective workplace violence prevention pro-

grams adapted to their specific worksite. It does not

address issues related to patient care and does not

provide standards or regulations.

The International Council of Nurses (ICN)

Position Statement

Abuse and Violence Against Nursing Personnel

http://www.icn.ch/images/stories/documents/publications/position

_statements/C01_Abuse_Violence_Nsg_Personnel.pdf

Condemns all forms of abuse and violence against

nursing personnel, ranging from passive aggression

to homicide and including sexual harassment

The Joint Commission

Sentinel Event Alert

Issue 45: Preventing Violence in the Health Care Setting

http://www.jointcommission.org/sentinel_event_alert_issue_45

_preventing_violence_in_the_health_care_setting_/

Addresses the increasing problem of violence in the

health care setting and provides suggested preven-

tive actions that organizations can take

Sentinel Event Alert

Issue 40: Behaviors That Undermine a Culture of Safety

http://www.jointcommission.org/sentinel_event_alert_issue_40

_behaviors_that_undermine_a_culture_of_safety/

Discusses intimidating and disruptive behaviors that

can foster medical errors and contribute to poor

patient satisfaction and to preventable adverse

outcomes

CASE STUDY 3-4: LEMUEL SHATTUCK

HOSPITAL: REDUCING ASSAULTS IN A

BEHAVIORAL HEALTH UNIT

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

services, as most of the patients are able to leave the units

during the day. These units provide mental health services

for residents of Massachusetts, but especially in the greater

Boston metropolitan area.

Defining the Program

In recognition of the risk for violence in this patient popula-

tion, and in response to a high rate of assaults by patients

against other patients and staff resulting in injuries,

MBMHU’s leadership began to examine evidence-based

practices and active programs in use at other facilities in

June 2010. Leaders established the primary goal to reduce

incidents of assault through culture change, training, and

clinical interventions. A multidisciplinary committee led by

the chief operating officer and the director of nursing of the

behavioral health units, with representation from social

work, occupational therapy services, mental health workers,

registered nurses, psychology services, and psychiatrists was

convened to facilitate development and introduction of a

violence reduction program within this organization. The

group worked to define what constituted violence (actual

versus attempted or threatened assaults).

The resulting program comprised three major activities:

1. The Safety and Respect Group – Staff and patients meet

twice each week to increase awareness of the impact of

violence and to suggest, teach, role-play and support

alternatives to violence. In addition, the Safety and

Respect group processes violent events in order to

increase appreciation for the impact of violence in a

therapeutic environment.

2. The Assaulted Staff Action Program (ASAP) – The ASAP

is an ongoing statewide Massachusetts program that is

operated at all Department of Mental Health inpatient

facilities. At MBMHU, its purpose is to render “emo-

tional first-aid” to assaulted staff, which includes debrief-

ing, support, and follow-up. While there are several staff

at this facility who provide these services, their numbers

have not been able to keep up with demand, so

MBMHU is attempting to recruit and train additional

responders.

3. Staff Education – Staff receive regular education on how

to prevent assault using effective communication tech-

niques, how to recognize warning signs of aggression,

and how to quickly identify when increased staff support

is indicated.

Development and implementation of strategy one, the

Safety and Respect Group, is described in more detail.

Introducing the Safety and Respect Group

The Safety and Respect group is a twice-weekly unit level

meeting that focuses on conflict resolution, the impact of

violence and assault, alternatives to violence, and other top-

ics that contribute to violence prevention. The Safety and

Respect pledge is said at the end of Safety and Respect

meetings so that there is a strong experiential connection for

patients on and off the unit (see Case Study Figure 3-3).

This pledge is written on T-Shirts in Spanish and

Portuguese for non-English–speaking patients.

Leadership for the group rotates between social work, occu-

pational therapy, psychology, rehabilitation staff, and mental

health workers, thereby supporting ownership at the unit

level. Group facilitators meet weekly to ensure that there is

consistency in how the group is run, as well as to plan for

future meetings.

This program was initially introduced on a single unit (10

South) before being rolled out over time to four other

units. In November 2011, the patients were offered an

opportunity to sign a Safety and Respect pledge for the

first time. Special T-shirts (see Case Study Figure 3-4)

made by patients were distributed to all who signed the

pledge. This event took place in the main lobby of the

hospital and acted to reinforce already-existing program

elements of violence reduction and, in particular, the

Safety and Respect Group. There continue to be periodic

pledge events on the units so that new admissions and

patients who did not pledge the first time can participate

when they are ready. Additional expressive therapies that

include the use of music and ritual (for example, a candle-

light walk) help to reinforce the groups’ progress toward

goals.

There has been robust patient participation in the group

and recently a peer representative with previous “lived

experience” has been hired to join the facilitator group.

Feedback from staff and patients in 10 South generated

interest in expanding the program. As of July 2012, the

program has become active on all targeted units.

Assessing Program Impact

The Safety and Respect Group sessions have been well

received by both patients and staff, who provided a great

deal of positive feedback. Participants expressed they felt

affirmed and supported; they appreciated having a safe place

to discuss violence and aggression, and they believe the

group supports a safer environment.

105

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Quantifying the impact of the Safety and Respect Group

was more challenging. Initially, the workgroup determined

that the unit of measurement for assessing program impact

would be the number of patients assaulting rather than the

number of assaults. This was because particular patients may

engage in repeated assaults, therefore the number of assault

events might be skewed by a single individual. Another

complicating factor was the fact that patients transferred

between units, and units were in different stages of imple-

menting the Safety and Respect Group meetings. To better

reflect the impact of the program, the group decided to

include only patients who did not transfer as part of the

unit’s evaluation. However, these factors limited the size of

the population of interest, so the evaluation period was

expanded to six months. Though the initial decline in

assaults did not maintain a consistent trend over time there

were many anecdotal observations of fewer “retaliatory

assaults” including assaults by patients who had been trans-

ferred to other units.

Eventually, the group determined that measuring “staff days

lost from injury resulting from an assault” was a more useful

and meaningful metric to track. Using this metric, the days

lost declined from 316 (during January to June of 2011) to

206 (from July to December), which was a 35% decrease.

This metric will continue to be used for program evaluation.

Celebrating Success and Looking Ahead

The hospital recognizes success at the unit-level in a number

of ways. Success is rewarded with verbal praise and special

food treats on the unit, such as an ice cream party after two

weeks of no assaults. There are visual reminders on the unit

as well, such as drawings of pizza slices depicting the num-

ber of days without an assault.

Patient and staff enthusiasm for the Safety and Respect

Group continues to reinforce the value of this strategy in

addressing safety for both patients and staff. The full imple-

mentation of the Safety and Respect Groups provides

greater opportunities to evaluate the effectiveness and

impact of the program over time.

106

Case Study Figure 3-3: Safety

and Respect Pledge

Source: Lemuel Shattuck Hospital. Jamaica Plains, MA. Used

with permission.

My Safety Pledge

Please recite this pledge out loud before signing, and

repeat it often!

May I be Safe

May I be Happy

May I be Healthy

May I be free from inner and outer harm

May my heart be filled with compassion and

wisdom

By signing this pledge I, ________________, commit

to actively participating in creating a safe and respectful

community.

By accepting a “We all deserve to feel safe” shirt, I will

wear it with pride and respect. I acknowledge that I can

spread the message of safety to the wider community. I

understand that safety is the responsibility of all of us.

Case Study Figure 3-4: Safety

T-Shirt

Source: Lemuel Shattuck Hospital. Jamaica Plains, MA. Used

with permission.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

Atlantic Health System

Morristown, New Jersey

The “Red Cell” Program

Atlantic Health System (AHS) has 100-plus facilities with

11,000 employees systemwide and logs 145,000 emer-

gency room visits annually between 3 acute care hospitals.

In total, AHS maintains approximately 9 million square

feet of physical plant and campus, spread throughout

New Jersey. The terrorist attacks of September 11, 2001,

followed by threats of anthrax and the sniper killings—as

well as concern for security-sensitive assets such as nuclear

material and vulnerable patient populations—served as an

impetus for a comprehensive review of security at AHS.

Protection and Security Services/Emergency Management

leadership brought together administration, clinical, and

patient safety staff to develop a new security-risk assess-

ment program. This new program that includes infiltra-

tion (unauthorized access) testing is called a “Red Cell”

program. Key elements of the program include quarterly

infiltration surveys (inspections/attempts to gain access to

security-sensitive areas) and Security Awareness Training

(orientation and annual employee education on basic

security principles). Any Red Cell program, by design,

targets security-sensitive areas to test infiltration and

report results.

Patients and families are engaged in education, too. For

example, parents in the mother-baby unit are educated on

infant security concepts promoted by the National Center

for Missing and Exploited Children, such as identifying staff

who wear specially marked identification cards. In addition

to the quarterly infiltration surveys, facility security person-

nel regularly sweep the building and are visible to patients

and families, especially at key times such as the end of visit-

ing hours.

A team of contracted plainclothes security and law

enforcement professionals conducts these surveys at AHS.

However, infiltration surveys could be conducted at a

minimal cost by using employees from different depart-

ments, sister facilities or even working with a volunteer

organization. The survey tests locks and other access con-

trol equipment as well as the ability of employees to ques-

tion or challenge an individual who may not be

authorized to be in the area. According to Alan Robinson,

Director of Protection and Security Services/Emergency

Management, “The employee is critical—the best equip-

ment can be defeated by one lax employee letting some-

one in who does not belong there.”

The impact of this innovative program has been evident in

feedback from staff, patients, and families. Using written

reports generated after each quarterly survey, data on the

infiltration prevention rate has been tracked since 2009. In

2010, only 47 breaches occurred for 565 attempts, showing

a successful infiltration prevention rate of 92% compared

with a rate of 78% in 2009, exceeding the established 2010

performance goal of 85% (see Case Study Figure 3-5, page

108).

One report generated from responses to the annual

employee engagement survey showed 86% of employees

answering favorably to the safety and security item, “My

location pays attention to health and safety.” Safety is now

ranked as one of the top 10 areas of satisfaction. In addi-

tion, statistics that include data from occupational medi-

cine demonstrate a significant reduction in workplace

violence between 2007 and 2010. Furthermore, according

to Donald Casey Jr., M.D., Chief Medical Officer and

Vice President of Quality for AHS, “Physicians have

noted the positive influence a safe environment has on

patients and families when they are selecting a facility for

care.”

In addition to positive internal responses, this program

along with several other security initiatives managed by the

AHS Protection and Security Services/Emergency

Management Department has been recognized by Security

Magazine and ranked fourth in a 2010 national review of

75 health care facilities. The magazine noted AHS as a secu-

rity leader that demonstrated increased responsibility and

utilized strategic business management approaches. As part

of the evaluation, organizations must also demonstrate

either quantitative and/or qualitative results. While the pro-

tection of sensitive materials and information is an impor-

tant program outcome, maintaining the safety of all

individuals within the health care facility is arguably its

greatest success. The programs’ approaches are Internet pro-

tocol (IP) driven and enterprise-centric, allowing the

107

CASE STUDY 3-5:

TLANTIC HEALTH: SECURING A HEALTH

SYSTEM RED CELL PROGRAM

Protection and Security Services Department/Emergency

Department to tie all AHS activities into a readily accessible,

reportable, and auditable form. Additional information on

the Atlantic Health System “Red Cell” Program is available

from Alan Robinson, Director of Protection and Security

Services/Emergency Management, Atlantic Health System,

Morristown, New Jersey at alan.robinson@atlantic

health.org.

Source

Security Magazine [Internet]. Troy (MI): BNP Media; c2012

[updated 2010 Nov 1; cited 2012 Jan 30]. 2010 Security 500 List;

[about 20 screens]. Available from: http://www.securitymagazine

.com/articles/2010-security-500-list-1.

US Department of Veterans Affairs

The Behavioral Threat Management Program

The Department of Veterans Affairs (VA), Veterans Health

Administration (VHA) is committed to providing safe and

effective care to all eligible veterans, including those who

demonstrate serious behavioral problems and disrupt health

care processes and facilities. Violence in the health care

workplace represents a substantial hazard to patients and

health care workers. Furthermore, violence and disruptive

patient behavior pose obstacles to the delivery of safe and

effective care. To meet this challenge, the VA initially devel-

oped a violence prevention program in the late 1970’s.*

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

108

Case Study Figure 3-5: Red Cell Graphs 2009–2010 (Atlantic Health)

Source: Atlantic Health System. Morristown, NJ. Used with permission.

CASE STUDY 3-6:

ETERANS HEALTH ADMINISTRATION

(VHA) REDUCING DISRUPTIVE PATIENT

BEHAVIOR: THE BEHAVIORAL THREAT

MANAGEMENT PROGRAM

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

Currently, the Behavioral Threat Management Program con-

sists of the following key components:

• Behavioral Threat Management Program (BTMP) –

The overarching program responsible for systems threat

assessment and management and for frontline worker

protection strategies

• Prevention and Management of Disruptive Behavior

Program (PMDB) – An employee education curricu-

lum

• Disruptive Behavior Committee (DBC) – Facility-

specific multidisciplinary teams under senior clinical

leadership

• Automated Safety Incident Surveillance and Tracking

System (ASISTS) – A national electronic injury manage-

ment system

• Patient Record Flags (PRF) – A behavioral flag visible

throughout the national electronic medical record system

managed by the DBC that provides guidance on manag-

ing potentially violent patients

Disruptive behavior can affect the delivery of care by inter-

fering with clinical examination, testing, and treatment. In

many private sector systems it results in patient dismissal,

though this approach represents a violation of patients’ due

process rights in the VA, as they are entitled to care by

statute. The overall goals and consequences of the BTMP

are improved quality of care for disruptive patients through

the following:

†

• Facility preparedness

• Successful interaction during the first few minutes of

contact—critical to preventing later difficulties

• Improved control of the patient’s behavior

• Delivery of better and more complete medical care

Health care providers have access to quick and reliable infor-

mation that assists them in deploying appropriate interven-

tions that enhance the safe delivery of care for both the

patient and staff.

Defining Program Components

Behavior Threat Management Program: BTMP has three pri-

mary purposes. It conducts training, including one-week

on-site mini-residencies for Disruptive Behavior Committee

(DBC) chairs and members in formal threat assessment and

management techniques, together with a monthly field

training and management call. It guides overall violence pre-

vention program evaluation and quality improvement.

Finally, it defines gaps in policies and knowledge and identi-

fies and provides solutions.

Prevention and Management of Disruptive Behavior: The

PMDB curriculum is divided into the following four

elements:

1) General knowledge

2) Personal safety skills (“break away” skills)

3) De-escalation skills

4) Therapeutic containment, that is, containment strategies

for out-of-control patients

Hands-on training is required for parts 2, 3, and 4. That

training relies on a national system of master trainers, with a

structured process for development. The master trainers

receive regular updates and skills evaluation/recalibration in

violence prevention and management training. They are

then deployed to develop trainers at the local facility level.

Recalibration conferences maintain trainers’ skill levels.

Local trainers and DBC members complete the education

and training for health care employees within each facility.

Facilities identify the level of required training through a

formal process of risk assessment. The curriculum has been

continuously evaluated and updated over the past 25 years.

The DBC was initially developed at the Portland Veterans

Administration Medical Center in the mid 1980s

‡

and was

implemented as national policy and infrastructure. The

DBC has a mission to conduct violence risk assessments and

recommend behavioral management strategies captured in a

note behind the electronic medical record. This interdiscipli-

nary facility-level committee reports directly to the chief of

staff. DBC membership across VA facilities must include a

senior clinician with expertise in assessment of patient

behavior, chief of staff, patient safety staff, a social worker,

facility safety manager, nurse manager, chief of mental

health services, and others.

As part of the threat assessment and management system,

the clinically-led DBC assesses violent incidents, distin-

guishes various forms of affective and predatory violence,

determines the likelihood of recurrence, and provides guid-

ance on prevention. Various approaches used by the DBC to

set limits with disruptive patients include warning letters,

patient conferences, employee education, amendments to

the patient’s treatment plan, and health care treatment

agreements.

§||

The VA pioneered a patient assessment process that com-

bines clinical knowledge and decision making with safety

and security approaches from law enforcement. It begins

with a formal evaluation of any veteran/patient who creates

109

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

a significant or repeated disturbance. The DBC conducts a

careful review of incident reports to identify patients at high

risk for repeated violence. An early survey at one VA facility

found that 25% of disruptive patients were responsible for

38% of all incidents.

†

If the committee reaches consensus

that there is a pattern of seriously disruptive behavior, a

Patient Record Flag (PRF) is added to the patient’s elec-

tronic database record.

The PRF is an electronic flag that is designed to alert med-

ical staff to the patient’s potential for violence. It appears as

an advisory note and triggers a subtle audio signal when the

patient is checked in for an appointment. The flag provides

a brief descriptive warning of past difficulties and allows cli-

nicians to initiate appropriate measures before interacting

with the patient. As with other medical information, pre-

cautionary flags are protected from general disclosure but

are not concealed from patients.

†

In 2002, the VA mandated the use of an electronic injury

management system to monitor injury reports and adverse

staff events.

The ASISTS database provides a source for

tracking the rate of reported employee assaults, which pro-

vides data for program assessment. A separate data system

reports workers’ compensation claims. Finally, VHA con-

ducts national questionnaire surveys regularly to assess

population-based response rates.

Changing the Assault Rates Over Time and

Improving Quality of Care

A study to evaluate specific program dimensions led to the

development and testing of a 110-question evaluation

instrument.

The dimensions that were evaluated include

the following: PMDB, committee formation and structure,

training, workplace practices, recording systems, patient

record flagging, formal threat assessment, environmental

control, security precautions, and security rounds. The study

was designed to examine the relationship between changes

in the assault rates over time and the implementation of the

violence prevention program in 138 VA facilities. After con-

trolling for variables, including hospital characteristics, geo-

graphic region, and others, Mohr et al.

reported a modest

change in national-level assault rates over a six-year period

(2004–2009). Study authors identified several possible rea-

sons for the modest change, including the following: off-

setting facility-level assault rate decreases and increases,

improved staff reporting of assaults leading to higher rates,

and an increased number of patients seeking services for

severe mental health conditions following deployment.

However, it was also observed that workers’ compensation

claims between 2001 and 2008 declined 40%, a fact that

may suggest a reduction in the severity of assaults. A survey

of VHA chiefs of staff shows satisfaction with violence pre-

vention processes and perceptions of increased program

effectiveness as policies are fully implemented. The violence

prevention strategies support deployment of consistent,

effective communication and behavior management tech-

niques, leading to improved cooperation and complete clinic

visits for difficult patients.

Important Lessons and Next Steps

The creation of a committee for clinical assessment and

management of violence and threatening behavior, com-

bined with training of frontline staff in verbal de-escalation

techniques and use of other behavior management strategies,

is a powerful tool that supports clinicians in managing diffi-

cult patients. The presence of a systemwide, accessible elec-

tronic record is essential for the appropriate functioning of a

flag that is visible on all charts, regardless of where the

patient presents for care. Patients and staff experience safer

and more effective clinical interactions when behavior man-

agement recommendations are consistently implemented

according to established policies.

Ongoing evaluation of program effectiveness, development

of additional training in personal safety skills, and a more

formal staff certification program and process are under

development over the next two years. Continued program

assessment will help identify other factors that impact the

assault rate and inform the development of effective inter-

ventions to protect patients and health care workers from

violence.

Case Study References

* Lehmann LS, Padilla M, Clark S, Loucks S. Training personnel in

the prevention and management of violent behavior. Hosp

Community Psychiatry. 1983;34:40–43.

† Drummond DJ, Sparr LF, Gordon GH. Hospital violence reduc-

tion among high-risk patients. JAMA. 1989 May

5;261(17):2531–2534. PubMed PMID: 2704113.

‡ Sparr LF, Drummond DJ, Hamilton NG. Managing violent

patient incidents: The role of a behavioral emergency committee.

QRB Qual Rev Bull. 1988 May;14(5):147–153. PubMed PMID:

3134637.

§ Sparr LF, Rogers JL, Beahrs JO, Mazur DJ. Disruptive medical

patients. Forensically informed decision making. West J Med.

1992 May;156(5):501–506. PubMed PMID: 1595274; PubMed

Central PMCID: PMC1003312.

110

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

|| Hodgson MJ, et al. 2010 VHA Survey on managing difficult

patient behavior (unpublished report). Department of Veterans

Affairs, 2011.

# Mohr DC, Warren N, Hodgson MJ, Drummond DJ. Assault

rates and implementation of a workplace violence prevention pro-

gram in the Veterans Health Care Administration. J Occup

Environ Med. 2011 May;53(5):511–516. PubMed PMID:

21555925.

3.5 Staffing, Fatigue, and

Support for Health Care–

Induced Emotional Distress

3.5.1 Workforce Staffing and Fatigue

Chapter 2 discussed practices of safety-sensitive industries

such as adopting measures to reduce human and organiza-

tional-related risks for occupational injury and perform-

ance errors. The value of adapting characteristics of high

reliability organizations to health care is to reduce the

potential for adverse events for both workers and patients.

Industries that operate around the clock share common

challenges to meet workplace staffing demands.

Organizational staffing practices are increasingly being

scrutinized against measures of performance and employee

well-being, enhancing the understanding of this relation-

ship. While health care organizations providing 24-hour

care have always faced staffing challenges, several trends

since the late 1970s, including nursing shortages,

increased patient acuity, and rapid admission-discharge

cycles, have influenced management practices. Specifically,

shifts for nurses have often increased from the traditional

8-hour rotation to 10–12 hours in length and often do

not follow traditional patterns of day, evening, and night

shifts.

122

Noted across diverse safety-sensitive industries,

work factors associated with increased risks for poor

employee well-being and performance errors include the

following:

• Shift work

2,122

• Rotating shifts and night shifts

122,123

• Extended work hours (more than 12 hours in a 24-hour

period)

2,124,125

•Overtime

124,126

• Excessive workloads

2,123,124

Research on the effects of shift work, extended work hours,

nighttime shifts, insufficient or nonexistent work breaks,

inadequate rest between tours of duty, and heavy workloads

documents elevated risks. These work factors may be associ-

ated with outcomes for employee well-being and perform-

ance that include the following:

• Fatigue and exhaustion

2,123–125,127,128

• Sleep deprivation

2,123,125,127

• Slowed reaction time

122,129

• Lapses of attention to detail

122,125,129

• Compromised problem solving

122,129

• Occupational injuries

2,122,125,126,128

• Increased incidence of errors

2,122,124–126

3.5.1.1 Impact on Patients and Workers

Health Care Workers

Occupations that have extended shifts, especially in excess of

12.5 hours, rotating shifts, and high workloads are associ-

ated with health care worker fatigue and sleep deprivation.

These in turn contribute to occupational injuries and acci-

dents as well as performance errors.

2,126,127

Fatigue is associ-

ated with cognitive, psychomotor, and behavioral

impairment.

122

Furthermore, sleep deprivation and fatigue

may adversely affect nervous, cardiovascular, metabolic, and

immune functioning.

In addition, overwhelming workload

demands and the need for speed contribute to personnel

taking shortcuts or using workarounds for patient care

processes. In one study of 393 registered nurses, 14% of

respondents reported working 16 or more consecutive hours

at least once during the 4-week survey period with the

longest reported shift lasting 23 hours and 40 minutes.

124

addition to working longer than the scheduled hours, nurses

often do not take meal or periodic rest breaks that might

improve short-term performance and reduce fatigue.

122,126,130

Even when taking breaks, nurses rarely relinquish patient

care responsibilities totally.

127

Multiple reasons such as diffi-

culty in handing off care responsibilities or fear of missing a

return call from a doctor make nurses reluctant to take

uninterrupted breaks.

127

Furthermore, organizational sched-

uling practices do not always allow time for recovery

between shifts or follow a clockwise (forward) directional

pattern (day–evening–night) that is easier to adjust to.

122

Finally, the risk of needlestick and sharps injuries is signifi-

cantly higher with extended-duration work shifts

125

and long

work hours with physical demands increase the risk for

work-related musculoskeletal injuries.

131

Heavy workloads and inadequate staffing levels, increasing

patient acuity levels, and unpredictable and often trau-

matic events all place emotional demands on staff and

contribute to the risk of burnout, exhibited in symptoms

111

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

including depersonalization and emotional exhaustion.

2,132

Burnout is known to be a significant factor in employee

well-being, job satisfaction, and turnover and has also

been associated with staff perceptions of a less safe envi-

ronment and a lower incidence of near-miss error report-

ing.

133

Burnout and exhaustion may also place staff at

greater risk for occupational injuries. Halbesleben found

that “employee exhaustion was positively associated with

the use safety workarounds, which were positively associ-

ated with occupational injuries.”

128,(p.8)

Like extended work shifts in nursing, traditional 24–30-

hour on-call shifts for physicians-in-training have raised

health and safety concerns for professionals and

patients.

125,126

Residents and interns working the traditional

extended-hour schedule make more serious medical errors

and experience increased risk for sharps injury and even

motor vehicle accidents.

125,126

Patients

An association between health care worker fatigue, sleep

deprivation, and patient safety has been explored in sev-

eral studies. In one study, the physicians-in-training work-

ing traditional schedules (24–30 hours) made 36% more

serious medical errors and five times as many serious diag-

nostic errors than those working limited hours.

134

Similarly, Rogers et al.

124

found the likelihood of making

nursing errors was three times higher for nurses working

shifts longer than 12.5 hours. More than half of the

reported errors (58%) and near errors (56%) involved

medication administration while other errors included

procedural errors, charting errors, and transcription

errors. Medication, procedural, and transcription errors all

pose a risk for patient harm.

The shortage of critical health care workers, especially

nurses, has contributed to the development of extended

hour shifts, heavy workloads, and overtime. Time pres-

sures created by a heavy workload can leave nurses with

little or no time to double check procedures and may lead

to dangerous workarounds—“alternative work processes

undertaken to ‘work around’ a perceived block in work

flow, such as a safety procedure.”

128

Retrospective studies

have linked staffing hours below target levels with

increased patient mortality.

135

An AHRQ evidence report

meta analysis concluded that increased nurse staffing in

hospitals was associated with lower mortality and failure

to rescue, along with better outcomes in ICU and surgical

patients.

136

3.5.1.2 Examples of Interventions

Regulations and Recommendations

Regulations and strategies to combat worker fatigue and

associated adverse outcomes have been developed in other

industries. For example, the National Transportation and

Safety Board has adopted measures including limiting time

on duty, mandating opportunities for sleep, and using con-

trolled rest periods.

137

However, in health care, there are no

universal measures in place across all states, health care set-

tings, and professions. By contrast, as early as 1993, the

European Union issued the European Working Time

Directive that was implemented by law in 1998 in the

United Kingdom.

126

This directive limits not only

physicians-in-training but also nurses and senior physicians

to a maximum of 13 consecutive hours of work and 48

hours of work per week.

126

While at this time there are no national regulations restrict-

ing the number of hours a nurse can voluntarily work,

some states have passed laws prohibiting mandatory over-

time.

122,124

A number of states have introduced some version

of safe RN staffing legislation aimed at addressing

nurse/patient ratios, which have become a concern due to

the impact of the nursing shortage.

138

Brief rest breaks and

meal breaks are not mandated in the Code of Federal

Regulations, and fewer than half the states have legislation

providing workers the legal right to these breaks.

122

However, evidence linking provider fatigue with occupa-

tional illness and injury as well as patient safety issues has

generated research and recommendations on work hours,

breaks, and scheduling. For example, evidence of the risks

of lengthy work tours led to the development of Duty

Hour Standards by the Accreditation Council for Graduate

Medical Education (ACGME) in 2003.

139

At the request of

Congress in 2007, the Institute of Medicine charged the

Committee on Optimizing Graduate Medical Trainee

(Resident) Hours and Work Schedules to evaluate available

evidence and develop strategies to optimize work sched-

ules.

123

The review led to recommendations that adjust-

ments to the 2003 ACGME rules were needed. The

committee noted that it is necessary to look beyond work

hours to consider factors such as sufficient time for sleep,

appropriate workload, and effective handovers of patient

care.

123

The recommendations are designed to dovetail with

an institutional culture of safety that reduces errors and

enhances patient safety. The ACGME released rule revi-

sions in July 2011, accompanied by new support features

such as “Frequently Asked Questions.”

139

The ANA also

112

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

advocates that employers provide a work schedule that

includes adequate rest and recuperation, sufficient staffing

resources to foster a safe and healthful environment that

encourages the elimination of excessive overtime, and shift

rotations.

129

The Institute of Medicine has recommended

that all nursing shifts greater than 12 hours be elimi-

nated.

123

Studies of evidence-based intervention schedules

have demonstrated the feasibility of implementing shorter

tours of duty; however, adoption of evidence-based sched-

uling has lagged in the United States.

In an effort to reduce performance errors and occupational

accidents and injuries, some safety-sensitive industries have

developed and implemented measures such as hours of serv-

ice regulations, appropriate scheduling practices, changes in

workplace design and technology, and fatigue management

research.

127

Fatigue risk-management systems represent a rel-

atively new approach being applied in high reliability indus-

tries that addresses several areas, including management

policy (such as limits on work hours); risk management; a

reporting system for employee-related near-miss events; inci-

dent investigation; training for managers and workers; sleep

disorder management; and corrective actions for continuous

improvement.

140

Providing a framework of regulations is a good starting point.

However, numerous employer and employee-generated inter-

ventions are needed to effectively achieve improved health and

safety outcomes for workers and patients. Researchers have

noted that success will require a change in culture, both insti-

tutional and professional. Adoption of evidence-based work

schedules requires significant planning and adequate workforce

resources. While evidence supports a recommendation that

health care workers take uninterrupted periodic rest and regu-

lar meal breaks, implementation requires a change in the cur-

rent cultural attitude that self-care should take a back seat to

patient needs.

127

Old policies prohibiting an employee from

napping while on duty still exist, and many organizations do

not have designated places convenient to work assignments

where employees can rest comfortably.

127

Employees must also

address lifestyle changes that support restful, adequate, and

uninterrupted sleep on a daily basis. Well-documented strate-

gies such as planned naps; strategic use of caffeine; creating a

quiet, dark, and designated area for sleep; turning off elec-

tronic devices; and so on fall to the employee to implement.

Table 3-5 offers a few suggestions for organizational and per-

sonal interventions to reduce health and safety risks for health

care workers and patients associated with workforce factors

and working conditions.

113

Table 3-5: Workforce and Working Condition Interventions to Improve

Worker Well-Being and Patient Safety

Professional and Educational

Organizations and Agencies

Health Care Organization Management and

Administration

Health Care Workers

Develop evidence-based work

strategies and interventions to

reduce risks to health care workers

and patients by pursuing research

priorities.*

Utilize the latest research on working conditions in

safety-sensitive industries, especially health care.

†

Assess for fatigue-related risks. This includes an

assessment of off-shift hours and consecutive shift

work and a review of staffing and other relevant poli-

cies to ensure they address extended work shifts and

hours.

†‡§

Be aware of the work environ-

ment and voice safety con-

cerns.

Pursue research recommendations

as proposed by NORA in State of

the Sector | Healthcare and Social

Assistance Chapter 5 “Work

Organization and Work-Related

Stress Disorders in the HCSA

Sector. (See Reference List)*

Comply with established hours-of-service regulations.

Eliminate mandatory overtime and monitor voluntary

overtime practices.

Work with staff nurses to develop flexible staffing

strategies.

||§

Since patient hand-offs are a time of high risk—espe-

cially for fatigued staff—assess the organization’s

hand-off processes and procedures to ensure that

they adequately protect patients.

#§

Limit voluntary overtime to

recommended hours of service

per week.

Evaluate impact of working

multiple jobs on personal

health and fatigue.

||**

Recognize obligation to patient

safety and personal health by

declining assignments if

impaired by fatigue.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

114

Table 3-5: Workforce and Working Condition Interventions to Improve

Worker Well-Being and Patient Safety (continued)

Professional and Educational

Organizations and Agencies

Health Care Organization Management and

Administration

Health Care Workers

Ensure professional curriculums

educate students in the relationship

between work-related fatigue, occu-

pational injuries and work errors,

and fatigue countermeasures.*

Create a partnership between occupational health,

patient safety, human resources, and nursing adminis-

tration to examine health and safety issues related to

workplace conditions for both workers and patients.

†

Create and implement a fatigue management plan

that includes scientific strategies for fighting fatigue.

These strategies can include: engaging in conversa-

tions with others (not just listening and nodding);

doing something that involves physical action (even if

it is just stretching); strategic caffeine consumption

(don’t use caffeine when you’re already alert and

avoid caffeine near bedtime); taking short naps (less

than 45 minutes).

#§

Educate staff about sleep hygiene and the effects of

fatigue on patient safety.

#||§

Provide opportunities for staff to express concerns

about fatigue. Support staff when appropriate con-

cerns about fatigue are raised and take action to

address those concerns.

Recognize signs and symp-

toms of work-related fatigue,

express concerns and seek

assistance as necessary (for

example, fatigue and stress

management programs).

†||

Develop good personal sleep

hygiene habits.

†

Implement recommended

fatigue-management strategies

when indicated.

Courses on improving patient safety

and quality of care could be offered

jointly to students in schools from

diverse disciplines (for example,

nursing, pharmacy, medicine, allied

health, health care management) to

foster teamwork and shared respon-

sibilities.

††

Collect and analyze data to identify patterns on work

hours for health care workers, as well as overtime,

scheduling patterns, absenteeism, workers’ compen-

sation claims, turnover, and employee satisfaction;

collect and analyze error reports and adverse events

for patients.

†

Contribute to organizational

assessments by participating in

research if available and com-

pleting staff surveys.

Support evidence-based scheduling

and hours of service regulations

when available.

||‡

Conduct screening to detect workers who exhibit

symptoms of sleep deprivation or work-related

fatigue.

†

(See resource list for an example of a

screening tool.)

Provide all staff with education on the risks of work-

related fatigue, signs and symptoms of sleep depriva-

tion, and the importance of rest and meal breaks.

†||

Work with organizational man-

agement to provide adequate

physical space for staff rest

breaks if not currently available

and policy permits.

Take periodic rest breaks and

uninterrupted meal breaks dur-

ing shifts.

†

Conduct research on creative

staffing patterns to meet patient

care needs and the well-being of

nurses.

Adopt evidence-based scheduling practices for

nurses and health care workers, for example, sched-

ule in a clockwise (forward) direction.

†

Encourage teamwork as a strategy to support staff

who work extended work shifts or hours and to pro-

tect patients from potential harm. For example, use a

system of independent second checks for critical

tasks or complex patients.

||§

Participate in work groups and

improvement initiatives to

examine staffing and

scheduling practices in your

organization.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

115

Table 3-5: Workforce and Working Condition Interventions to Improve

Worker Well-Being and Patient Safety (continued)

Professional and Educational

Organizations and Agencies

Health Care Organization Management and

Administration

Health Care Workers

Conduct research on the application

of fatigue countermeasures (such

as checklists) developed in other

safety-sensitive industries.

#||

Incorporate practices that promote high reliability and

bridge patient and worker safety activities.

Develop policies that support periodic rest and regu-

lar meal breaks by providing uninterrupted coverage

of all responsibilities (including coverage of both

admissions and all continuing care by another

provider) and carrying pagers and phones.

Remove policies that are in conflict with evidence-

based recommendations for rest during work shifts.

Consider fatigue management, ergonomics, and

human factors research related to workplace design

and technology.

#§

Report unsafe working condi-

tions.**

Maintain vigilance for safety

risks and hazards. Share con-

cerns and search out solutions.

Comply with recommended

practices to combat fatigue

during work shifts, such as tak-

ing rest and meal breaks.

#†

Support research and development

for, and dissemination of, evidence-

based building design that supports

patient and worker safety and

health.*

Assess physical structure for ways to provide a cool,

dark, quiet, comfortable room in close proximity to

patient care assignments for staff rest breaks. If nec-

essary, provide eye masks and earplugs.

#§

Utilize designated dining and

break facilities for meals and

rest periods.

†‡

Examine error and near-miss

reporting systems developed in

other safety-sensitive industries for

adaptability to health care.

Encourage error and near error reporting as part of

quality improvement efforts and to better understand

the relationship between working conditions and

patient safety.

Consider fatigue as a potential contributing factor

when reviewing all adverse events.

Participate in voluntary report-

ing of safety issues impacting

staff and patients, near-miss

and adverse safety events to

expand the knowledge base,

and provide learning opportuni-

ties.

Sources:

* US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and

Health [Internet]. State of the Sector | Healthcare and Social Assistance: Identification of Research Opportunities for the Next Decade of

NORA. DHHS (NIOSH) Publication Number 2009-139. Available from: http://www.cdc.gov/niosh/docs/2009-139.

†

Witkoski A, Dickson VV. Hospital staff nurses’ work hours, meal periods, and rest breaks. A review from an occupational health nurse per-

spective. AAOHN J. 2010 Nov;58(11):489–497; quiz 498–499. doi: 10.3928/08910162-20101027-02. Review. PubMed PMID: 21053797.

‡

Page A, editor; Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington (DC): National

Academies Press, 2004.

The Joint Commission [Internet]. Oakbrook Terrace (IL): The Joint Commission; c2012 [updated 2011 Dec 14; cited 2011 Dec 15]. Sentinel

Event Alert Issue 48: Health care worker fatigue and patient safety; [about 4 p.]. Available from: http://www.jointcommission.org/sea_issue_48/.

Ellis JR [Internet]. Seattle (WA): Washington State Nurses Association; c2008 [updated 2008; cited 2012 Jan 30]. Quality of Care, Nurses’

Work Schedules, and Fatigue; [about 24 p.]. Available from: http://www.wsna.org/Topics/Fatigue/documents/Fatigue-White-Paper.pdf.

Scott LD, Hofmeister N, Rogness N, Rogers AE. Implementing a fatigue countermeasures program for nurses: A focus group analysis. J

Nurs Adm. 2010 May;40(5):233–240.

** American Nurses Association [Internet]. Washington (DC): American Nurses Publishing; c2006 [updated 2006 Dec 8; cited 2011 Nov 6].

Assuring Patient Safety: Registered Nurses’ Responsibility in All Roles and Settings to Guard Against Working When Fatigued [about 6 p.].

Available from: http://gm6.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/ANAPositionStatements/Position-

Statements-Alphabetically/Copy-of-AssuringPatientSafety-1.pdf.

††

Buerhaus PI, Donelan K, Ulrich BT, Norman L, DesRoches C, Dittus R. Impact of the nurse shortage on hospital patient care: Comparative

perspectives. Health Aff (Millwood). 2007 May-Jun;26(3):853–862.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

116

Resources 3-8: Workforce Staffing and Fatigue

Title and Website Description

Accreditation Council for Graduate Medical Education (ACGME)

Standards

Duty Hours

http://www.acgme.org/acgmeweb/tabid/271/GraduateMedical

Education/DutyHours.aspx

Standards for duty hours for the graduate medical

trainee (residents)

Agency for Healthcare Research and Quality (AHRQ)

Publication

Patient Safety and Quality: An Evidence-Based Handbook for Nurses

http://www.ahrq.gov/qual/nurseshdbk/

A comprehensive handbook for nurses on topics

related to patient safety and quality of care; working

conditions and the work environment are addressed.

American College of Occupational and Environmental Medicine (ACOEM)

Guidance Statement

Fatigue Risk Management in the Workplace

Lerman SE, Eskin E, Flower DJ, George EC, Gerson B, Hartenbaum

N, Hursh SR, Moore-Ede M. American College of Occupational and

Environmental Medicine Presidential Task Force on Fatigue Risk

Management. Fatigue risk management in the workplace. J Occup

Environ Med. 2012 Feb;54(2):231-58. PubMed PMID: 22269988.

http://www.acoem.org/uploadedFiles/Public_Affairs/Policies_And

_Position_Statements/Fatigue%20Risk%20Management%20in%20the

%20Workplace.pdf

This guidance statement by the ACOEM addresses

fatigue as an unsafe condition in the workplace. The

statement describes the benefits and activities

associated with developing and implementing a

fatigue risk management system in health care

organizations.

American Nurses Association

Position Paper

Assuring Patient Safety: Registered Nurses’ Responsibility in All Roles

and Settings to Guard Against Working When Fatigued (2006)

http://www.nursingworld.org/MainMenuCategories/Policy-

Advocacy/Positions-and-Resolutions/ANAPositionStatements/Position-

Statements-Alphabetically/Copy-of-AssuringPatientSafety-1.pdf

A position statement on the registered nurse’s

responsibility in the evaluation of his/her degree of

fatigue when deciding to accept or reject any assign-

ment extending beyond their regularly scheduled

work day or week, including a mandatory or voluntary

overtime assignment

Position Paper

Assuring Patient Safety: The Employers’ Role in Promoting Healthy

Nursing Work Hours for Registered Nurses in All Roles and Settings

(2006)

http://www.nursingworld.org/MainMenuCategories/Policy-

Advocacy/Positions-and-Resolutions/ANAPositionStatements/Position-

Statements-Alphabetically/AssuringPatientSafety.pdf

A position statement addressing employer roles in the

development of policies and procedures that promote

healthy nursing work hours and patterns that do not

extend beyond the limits of safety for both nurses

and patients

Journal Article

Occupational Fatigue Exhaustion Recovery Scale (OFER)

Winwood PC, Lushington K, Winefield AH. 2006. Further development

and validation of the Occupational and Fatigue Exhaustion Recovery

(OFER) scale. J Occup Environ Med. 2006 Apr;48(4):381–389.

Article describes a tool for screening nurses at risk

for work-related fatigue. It has three subscales to

determine acute fatigue, chronic fatigue, and intershift

recovery.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

3.5.2 Work-Related Emotional

Injuries and Illness

High reliability organizations are continuously aware of the

possibility of failure and therefore promote transparency by

encouraging all employees to report adverse safety events

and near-miss events. Their emphasis is on system failures,

not individual failures. However, for the health care profes-

sional involved in an adverse event, or even a near miss, it is

a very personal experience. Errors and near errors as well as

tragic patient outcomes such as deaths—unanticipated or

not—trigger intense emotional responses in even the most

experienced clinician.

141

While growing attention has right-

fully been focused on making system improvements to

increase safety and supporting patients who are impacted by

errors, equal consideration has not always been given to the

health care professionals, including physicians, involved in

adverse medical events.

142

Newer studies are contributing to a body of knowledge about,

and understanding of, the emotional impact on professionals

who have been referred to as “second victims.”

141,143–145

The

term second victim was used by Dr. Albert Wu more than 10

years ago to describe the emotional distress experienced by

physicians following a medical error.

146

The term is now often

applied across professional disciplines to describe the personal

impact of medical error, near error, and unanticipated clinical

events (see Sidebar 3-10, page 118). In addition to developing

a greater understanding of the impact on the health care

worker, emerging research is examining the potential influence

on future performance and quality of care. The issue is also

receiving some attention in the public media, as in the 2010

Reader’s Digest article “White Coat Confessions,” which shares

real-life stories of medical errors and near errors from profes-

sionals who convey the feelings of guilt and emotional distress

they suffer.

147

3.5.2.1 Impact on Patients and Workers

For decades a culture that has placed emphasis on individual

performance and expectations that health professionals are

“error-free”

143

has contributed to the fear of reporting errors,

leaving second victims to suffer alone. Symptoms reported

by second victims range widely from anxiety, depression,

117

Resources 3-8: Workforce Staffing and Fatigue (continued)

Title and Website Description

National Institute for Occupational Safety and Health

Publication

Overtime and Extended Work Shifts: Recent Findings on Illnesses,

Injuries and Health Behaviors (2004)

http://www.cdc.gov/niosh/docs/2004-143/pdfs/2004-143.pdf

This document summarizes scientific findings to date

concerning the relationship between overtime and

extended work shifts on worker health and safety

Report

Caruso CC and Geiger-Brown J.

Chapter 5: Work Organization and Work-Related Stress Disorders in

the HCSA Sector

In: US Department of Health and Human Services, Centers for

Disease Control and Prevention, National Institute for Occupational

Safety and Health [Internet]. State of the Sector | Healthcare and

Social Assistance: Identification of Research Opportunities for the

Next Decade of NORA. DHHS (NIOSH) Publication Number 2009-

139. Available from: http://www.cdc.gov/niosh/docs/2009-139

This 236-page document, developed by the NORA

Healthcare and Social Assistance Sector Council,

addresses the "state of the sector," including magni-

tude and consequences of known and emerging

health and safety problems, critical research gaps,

and research needs that should be addressed over

the next decade of NORA. Chapter 5 discusses work

organization and work-related stress disorders.

The Joint Commission

Sentinel Event Alert

Health Care Worker Fatigue and Patient Safety

http://jointcommission.org/sea_issue_47/

An informational paper describing the impact of, and

contributing factor to, worker fatigue. Actions are sug-

gested that health care organizations can take to help

mitigate the risks of fatigue resulting from extended

work hours and potential adverse patient outcomes.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

feelings of inadequacy or concerns about their ability to per-

form their jobs, to burnout and even thoughts of sui-

cide.

141,144,145

Second victims who do not receive support may

experience emotional distress, loss of sleep, and difficulty

concentrating, which may diminish future job perform-

ance.

143

Based on a review of the literature, Schwappach and

Boluarte

145

suggest a reciprocal cycle of emotional distress,

burnout, and increased risk of future error potentially

impacting patient care (see Figure 3-1).

In addition to emotional injury, outcomes for health care

professionals involved in recognized medical errors can

include litigation and in a few instances

have even resulted in criminal prosecu-

tion. Other tragedies have included job

termination and even suicide, as was the

case for Kimberly Hiatt (see Sidebar 3-

11, page 119).

Patients can experience a range of physi-

cal outcomes from no negative impact to

death as a result of medical errors and

adverse safety events. They may also

experience emotional injuries and finan-

cial trauma. In a review of literature,

O’Connor et al.

148

noted that after learn-

ing about a safety incident, patients may

feel sad, anxious, depressed, or trauma-

tized. In addition, they fear further

errors and harm. Although patients are

increasingly encouraged to be a “partner

in care,” their perspective is not rou-

tinely elicited following a safety event.

149

Family members

may feel guilty for not being able to protect their family

member from harm.

148

The direct and indirect costs associated with adverse medical

events are significant. Medical treatment costs for the

patient may be compounded by extended length of stay and

even possible litigation. Health care workers may have

increased absenteeism, illness, and diminished job perform-

ance. However, constructive outcomes have been reported

when the health care professional receives support and is not

targeted for blame by the organization.

3.5.2.2 Examples of Interventions

A rapid response team for second victims developed at one

academic health care system is described in Case Study 3-7,

page 119. Attending quickly to the emotional needs of health

care professionals involved in events benefits their recovery

and ability to return to optimum job performance. Resources

to support second victims may be available within an organi-

zation. For example, employee assistance programs and chap-

lain services may be utilized. Also, training can be provided to

employees willing to be part of a peer support team.

Interventions to support the emotional needs of patients

who have experienced an adverse safety event have been sug-

gested. Developing patient-assisted incident reporting to

enhance the organization’s incident reporting system and

obtain the patient’s perspective can provide valuable infor-

118

Sidebar 3-10: Definition of

Second Victim

“A second victim has been described as a health care

provider involved in an unanticipated adverse patient

event, medical error and/or a patient-related injury who

becomes victimized in the sense that the provider is

traumatized by the event. Frequently, second victims feel

personally responsible for the unexpected patient out-

comes and feel as though they have failed their patients,

second-guessing their clinical skills and knowledge

base.”

Source: Scott SD, et al. Caring for our own: Deploying a sys-

temwide second victim rapid response team. Jt Comm J Qual

Patient Saf. 2010 May;36(5):233.

Figure 3-1: Reciprocal Cycle of Error

Involvement, Emotional Distress, and Future

Errors

Source: Schwappach DL, Boluarte TA. The emotional impact of medical error involvement

on physicians: A call for leadership and organisational accountability. Swiss Med Wkly.

2009 Jan 10;139(1-2):9–15. Review. PubMed PMID: 18951201. Used with permission.

mation.

149

In fact, in postdischarge surveys, patients have

reported safety incidents that occurred during their hospital-

ization that were not previously known.

149

Reports from

patients may identify opportunities for safety improvements

that were previously unrecognized. For example, eliciting a

patient’s detailed account of events surrounding a fall may

uncover contributing factors not known to the caregiver,

clarify educational needs, and increase patients’ participation

in their care. Good provider–patient communication has

been reported to diminish the emotional trauma experi-

enced by patients following a safety incident.

148

Patients who have experienced an adverse event need infor-

mation to help them cope, such as an explanation of what

happened, how and why it happened, how it will impact

their health, and how future incidents might be prevented.

148

A majority of patients indicate that they want disclosure fol-

lowing an event. Disclosing safety incidents of which the

patient is not aware is a complex issue. While health care

professionals and patients support the concept of disclosing

adverse events, there are identified barriers to disclosing as

well as reasons for disclosure.

148

O’Connor et al.

148

present

the issue in Table 3-6.

What is clear is that as organizations continue to embrace a

culture of safety, comprehensive approaches should be

implemented that support patients and health care workers

who are involved in unexpected clinical and adverse medical

events. Each organization will need to ensure that manage-

ment of safety events reflects core organizational safety val-

ues by protecting patients and providers both medically and

emotionally.

Concern over the emotional trauma experienced by staff fol-

lowing unanticipated clinical events and its impact on

employee well-being and patient safety was the impetus for

development of a rapid response intervention at the

University of Missouri health care system. The program,

grounded in internal research, is described in Case Study 3-7.

A Second Victim Rapid Response Program

University of Missouri Health Care

A Second Victim Rapid Response Program

University of Missouri Health Care (MU Health Care) is an

academic health care system that includes six facilities with

approximately 5,300 faculty, staff, students, and volunteers.

In 1998 MU Health Care designated the Office of Clinical

Effectiveness (OCE) to oversee clinical outcomes and a

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

119

Sidebar 3-11: Kimberly Hiatt

Story

This tragedy highlights the issues surrounding, and impact

of, a medical error. There are two victims, patient and

health care provider, involved in this serious medication

error. Kimberly Hiatt, a veteran nurse with a 24-year

career at one facility, acknowledged making an error

resulting in the administration of an overdose of calcium

chloride to a fragile baby. Hiatt immediately reported mak-

ing the mistake to other staff and in the organization’s

electronic reporting system. Tragically, the baby who was

critically ill, later died although it was not clear that the

mistake could be identified as the cause. Her friends and

family stated that Hiatt was devastated. In the aftermath of

the error, she experienced intense media attention, job

loss, and a licensure sanction from the state nursing com-

mission and feared she would never be able to work as a

nurse again. Ultimately, overcome with despair, she com-

mitted suicide six months after the mistake.

Adapted from source: Aleccia J. MSNBC Digital Network.

New York: MSNBC; c2012 [updated 2011 Jun 27; cited 2012

Jan 18]. Nurse’s suicide highlights twin tragedies of medical

errors; [about 8 screens]. Available from: http://www.msnbc

.msn.com/id/43529641/ns/health-health_care/t/nurses-suicide

-highlights-twin-tragedies-medical-errors.

Sidebar 3-12: Value Added by

Eliciting the Patient Perspective

• Improved understanding of an event’s contributing

factors and possible solutions or interventions

• Increased patient engagement in their care

• Opportunity to learn about other safety or quality con-

cerns of the patient or family

• Opportunity to evaluate the patient’s understanding of

policies and educational materials

Source: Millman EA, et al. Patient-assisted incident reporting:

Including the patient in patient safety. J Patient Saf. 2011

Jun;7(2):106-108. Used with permission.

CASE STUDY 3-7:

NIVERSITY OF MISSOURI:

ARING FOR OUR OWN: CLINICIAN

SUPPORT FOLLOWING UNANTICIPATED

CLINICAL EVENTS

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

transformation of the safety culture.* The OCE’s work

included the development and implementation of an elec-

tronic patient safety reporting system, coordination of safety

investigations, and management of root cause analyses for

the system. Safety event investigations revealed that in the

aftermath of patient safety and unanticipated clinical events,

clinicians were sometimes experiencing significant profes-

sional and personal distress. It was recognized that events

such as patient deaths, even when expected due to terminal

illness, and caring for very young patients could produce

suffering among staff. Additionally, traumatic events experi-

enced by coworkers or their family members sometimes pro-

duced distress. A growing awareness of this important staff

health and well-being issue led Susan D. Scott, RN, MSN,

patient safety officer at MU Health Care, and doctoral stu-

dent at the MU Sinclair School of Nursing, to elevate the

issue to senior management. Executive leaders responded by

commissioning an interprofessional team to design a sup-

port strategy to explore what is increasingly being recog-

nized throughout the health care community as “the second

victim phenomenon.” The team was composed of represen-

tatives from patient safety, risk management, physicians,

nursing staff, managers, and clergy, among others. A three-

year research effort followed that included program plan-

ning, design, testing, and specialized training. It culminated

in the deployment of MU Health Care’s second victim rapid

response team, forYOU. The term second victim has been

described as a “health care provider involved in an unantici-

pated adverse patient event, medical error and/or a patient-

related injury who become victimized in the sense that the

provider is traumatized by the event. Frequently, second vic-

tims feel personally responsible for the unexpected patient

outcomes and feel as though they have failed their patients,

second-guessing their clinical skills and knowledge base.”*

Designing a Rapid Response Program for

Second Victims

The second victim rapid response program at MU Health

Care supports health care clinicians and staff members,

because anyone who is involved with patient care could

experience an unexpected clinical event or other emotional

trauma and thereby become second victims. After studying

the literature and several other peer support programs, the

team conducted surveys of employees to understand the

120

Table 3-6: Reasons to Disclose and Barriers to Disclosure of

Adverse Events

Reasons to Disclose Adverse Events Barriers to Disclosure of Adverse Events

Patients have a right to know what has happened to them,

providing an ethical imperative to disclose adverse events.

Concerns over increased litigation costs

Disclosure is essential to allow consent for ongoing care. Fear of loss of relationship with the patient

Good communication around an adverse event strengthens

physician-patient relationship.

Fear of loss of reputation or damage to career progression

Later discovery of an adverse event that has not been dis-

closed is damaging to the physician-patient relationship.

Lack of institutional support

Disclosure can provide an opportunity for forgiveness and

reconciliation after an adverse event.

Absence of training in how to go about disclosure

conversations

Good disclosure practice makes effective reporting and learn-

ing more likely.

The emotional impact of adverse events on clinicians

Disclosure allows for just compensation to be sought follow-

ing an adverse event.

Disclosure may reduce the likelihood of litigation following an

adverse event.

Source: O’Connor E, Coates HM, Yardley IE, Wu AW. Disclosure of patient safety incidents: A comprehensive review. Int J Qual Health Care.

2010 Oct;22(5):371–379. PubMed PMID: 20709703. Used with permission.

Chapter 3: Specific Examples of Activities and Interventions to Improve Safety

frequency and nature of the second victim experience at

MU Health Care. Surveys were completed by 898 employ-

ees across six facilities and from four professional groups.

Approximately 30% (269/898) reported experiencing prob-

lems ranging from anxiety to questioning their job perform-

ance abilities as a result of some kind of event within the

past 12 months. Survey results also suggested desirable orga-

nizational support structures and workplace interventions.

Common narrative themes emerged, and foremost among

these was “to implement an institutionally sanctioned respite

away from the care environment immediately after an event

to allow the second victim to compose himself/herself before

resuming patient care.”* The narrative experiences provided

by respondents, together with suggestions for supportive

interventions, were formalized in the Scott Three-Tiered

Interventional Model of Second Victim Support (see Figure

3-6). Based on the survey results and the team’s research,

senior leaders strongly supported the deployment of a rapid

response team for second victims to provide on-demand

emotional support as described in the model. In summary,

the research phase defined what a second victim is, identi-

fied multiple recovery stages and related support needs, and

led to the formulation of a three-tiered interventional

strategy.

Implementing the forYOU Team

Three executive champions (the chief operating

officer/chief nurse executive, the chief quality officer, and

the chief medical officer) ensure that resources are avail-

able for staff training, education, team infrastructure, and

ongoing team development and evolution. In March

2009, the rapid response forYOU Team was officially

deployed to serve all six MU Health Care facilities. The

guiding principle of the team is the understanding that

the three-tiered model is used to facilitate the second vic-

tim’s progression through the stages of recovery according

to their unique needs. Team training initially included 18

hours of didactics, small-group work, and simulation.*

Team members received education on a wide range of top-

ics, from basic second victim responses to the stages of

121

Case Study Figure 3-6: Scott Three-Tiered Interventional Model of

Second Victim Support

Source: Scott SD, et al. Caring for our own: Deploying a systemwide second victim rapid response team. Joint Commission Journal on

Quality and Patient Safety. 2010;36(5):233–240. Used with permission.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

122

recovery, as well as active listening skills, stress manage-

ment techniques, referral procedures, and more.

Currently, the 84 team members, considered “clinical life-

guards,” work in high risk clinical areas (for example,

operating rooms, intensive care units, emergency depart-

ment, and palliative care services) and high risk clinical

teams (such as rapid response and code blue) across all

shifts. There is a single individual responsible for system-

wide team administration; however, each facility has a

team leader who coordinates all program components and

team members within that institution. One of the leaders

is on call by pager 24/7 with a goal of ensuring that any

health care provider or staff member suffering from a sec-

ond victim experience receives psychosocial support before

leaving the facility. Immediate intervention and support

provided by supervisors and peers is supplemented by

team members and can be further enhanced by expedited

referral to internal professional counseling services as

necessary.

Evaluating the Impact of the forYOU Team

Tier 1 interventions provide basic care and support by

peers and supervisors but are not captured in formal sys-

tem tracking. Attempts to monitor are focused on captur-

ing Tier 2 and Tier 3 interventions. Data gathered during

the first two years of program implementation reveal that

a total of 375 individual clinicians have been served by

the second victim rapid response team. Nursing personnel

represented 58% of these individuals, 24% were medical

staff, and 18% were allied health care personnel.* Reasons

for activating the team included unexpected patient out-

comes (54%), unit- or staff-related issues (30%), and

medical errors (16%). Other measures targeted to assess

program impact are staff turnover and vacancy rates.

Items added to MU Health Care’s AHRQ modified

patient safety culture survey in 2007 will be compared

with 2009 (program implementation) and subsequent sur-

veys. Substantial staff recruitment and training cost sav-

ings may be realized if a clinician receives support and

remains in his or her position after an event rather than

leaving. Finally, anecdotal feedback suggests that the pro-

gram has been extremely helpful to second victims.

Sample comments such as the following confirm the pro-

gram’s impact on a personal level:

“To have someone call me out of the blue, just to

offer support, was a wonderful thing! It was like a

burden was lifted off of me, knowing I didn’t have to

get through it alone.”—MD, second victim

“Helping with the team de-briefing was one of the

most satisfying things that I have done during my

tenure here. It was so fulfilling to help others in such

a unique way. It made me feel really, really good.”

—Social Worker, peer supporter

Ongoing program improvement and assessment, as well as

future descriptive research is planned. Recently a 10-module

toolkit was made available to health organizations to

develop and implement a second victim support system.

†

Key Lessons for a Successful Second Victim

Rapid Response System

To ensure that a second victim rapid response system can

successfully be implemented, the following key elements

and recommendations are presented:

1. Supportive leadership and a sophisticated safety culture.

The health care system with a strong culture of safety

immediately responds not only to support patients and

family members but also clinicians.

2. A comprehensive support network for clinicians. Support

requires engaged leadership, preparedness, and a strong

infrastructure for clinician support.

3. Institutional awareness of the second victim phenomenon.

There must be a comprehensive education and market-

ing plan to address three distinct groups within a health

care facility. Plans should include the following factors:

a. All clinicians know about the second victim experi-

ence, what institutional response to anticipate, and

how to aid their colleagues/peers.

b. Supervisory training is provided so that leaders are

familiar with the second victim phenomenon and the

strategies/key messages that clinicians and staff mem-

bers need during this stressful period.

c. An education plan is in place for peer supporters to

provide in-depth information about the second vic-

tim experience, strategic support interventions, and

how to access additional assistance.

4. A formal institutional response plan for addressing the

period of time immediately following an unanticipated clin-

ical event that also meets the unique needs of the second vic-

tim. The three-tier emotional support structure was

developed to ensure that a multitude of needs could be

met.

5. 24/7 immediate access to provide support and guidance for

a second victim or for a member of the rapid response team

who needs additional guidance/assistance with a particu-

larly difficult case. Health care organizations frequently

have internal resources available, such as chaplains, social

workers, and clinical health psychologists, as well as

access to employee assistance programs (EAP). The

referral process must be clearly defined to ensure that the

second victim’s personal and professional needs are

satisfactorily addressed in a timely and expedited

manner.

Case Study References

* Scott SD, Hirschinger LE, Cox KR, McCoig M, Hahn-Cover K,

Epperly KM. Caring for our own: Deploying a systemwide second

victim rapid response team. Jt Comm J Qual Patient Saf. 2010

May;36(5):233–240. PubMed PMID: 20480757.

† Pratt S, Kenney L, Scott SD, Wu AW. How to Develop a Second

Victim Support Program: A Toolkit for Health Care

Organizations. The Joint Commission Journal on Quality and

Patient Safety. 2012;38(5):235–240.

Additional Resources

Wu AW. Medical error: The second victim. The doctor who

makes the mistake needs help too. BMJ. 2000 Mar

18;320(7237):726–727.

Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J,

Hall LW. The natural history of recovery for the healthcare

provider “second victim” after adverse patient events. Qual

Saf Health Care. 2009 Oct;18(5):325–330.

(Website) University of Missouri Health System: forYOU

Team—Caring for Our Own. Available at:

http://www.muhealth.org/secondvictim.

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Resources 3-9: Work-Related Emotional Injury

Title and Website Description

GE Health Care

Webcast

The Second Victim

Live video and transcript available at:

http://nextlevel.gehealthcare.com/videos/webcasts/the-second

-victim.php

A webcast featuring Dr. Albert Wu (Johns Hopkins

University) and Jim Conway (Harvard School of

Public Health) discussing what a successful second

victim support program is, how to measure success,

how leaders can create a culture that supports sec-

ond victims, and how to plan a response to an

adverse event

Institute for Healthcare Improvement (IHI)

White Paper

Respectful Management of Serious Clinical Adverse Events

http://www.ihi.org/knowledge/pages/IHIwhitepapers/respectful

managementseriousclinicalAEswhitepaper.aspx

This white paper introduces an overall approach and

tools designed to support two processes: (1) The

proactive preparation of a plan for managing serious

clinical adverse events; and (2) the reactive emer-

gency response of an organization that has no such

plan

International Critical Incident Stress Foundation

Courses and Training Seminars

http://www.icisf.org

A resource for education, training, consultation, and

support services. Courses offered in crisis intervention.

Medically Induced Trauma Support Services (MITSS)

Tools and Information

Nonprofit organization

http://www.mitss.org

http://www.mitsstools.org

Tools and information to support patients, families,

and clinicians impacted by medical errors and

adverse medical events

The Joint Commission

The Joint Commission Journal on Quality and Patient Safety

Tool Tutorial

Pratt S, Kenney L, Scott SD, Wu AW. How to Develop a Second

Victim Support Program: A Toolkit for Health Care Organizations. The

Joint Commission Journal on Quality and Patient Safety.

2012;38(5):235–240.

This article describes the development of a set of

tools designed to assist health care organizations in

developing and implementing a second victim support

system

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130

Patient and Worker Safety

Synergies—

Key Themes and Action Steps

to Meet Challenges and

Achieve Success

his monograph presents material intended to raise the reader’s awareness of

the common health and safety risks shared by patients and workers in health

care. Through literature references and links to resources, readers can learn

more about the synergies between worker and patient safety in specific topic

areas and about making safety a core organizational value, which is characteristic of

highly reliable industries. The case studies from organizations that have implemented

integrated patient and worker safety initiatives highlight valuable experiences. This

chapter summarizes the key points, recommendations, and action steps identified dur-

ing a vigorous day of discussions at the project roundtable meeting in July 2011, as well

as those identified from the collaborating organizations and from the literature.

Regardless of the specific safety risk, implementing a framework of high reliability coupled with the use of support-

ing strategies will help organizations adopt a culture of safety that transcends individual improvement initiatives

and departmental walls. Recommendations for successfully integrating patient and worker safety identified at the

roundtable meeting, together with common strategies and action steps covered in this monograph are summarized

in Sidebar 4-1, page 132.

4.1 Future Research and Activities

Since 1996, the National Institute for Occupational Safety and Health (NIOSH) implemented a partnership

131

– Chapter 4 –

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

132

Sidebar 4-1: Themes,

Recommendations, and Action

Steps from the Roundtable

Meeting and Chapters

The roundtable meeting produced a wealth of recom-

mendations for successfully integrating patient and

worker safety. The recommendations are described

here, together with common strategies and action steps

covered in this monograph.

Encourage leaders to make patient and worker safety a

core organizational value.

• Establish a vision that makes safety for both patients

and workers a core value across the entire organiza-

tion.

• Establish specific goals and incorporate plans to com-

municate and achieve the goals into strategic plan-

ning activities.

• “Walk the talk.” Become highly visible by making

safety rounds at the unit and department level to

actively engage with frontline staff.

• Communicate daily with all levels of management to

learn about safety events through vehicles such as a

“daily huddle.”

• Employ real-life patient and worker stories to engage

the “hearts and minds” of leaders, managers, and

staff.

• Engage board members in discussions of safety for

both workers and patients. Share data on organiza-

tional performance.

• Communicate successes both internally and exter-

nally to the community through media and to peers

through conferences, and so on.

Identify opportunities to integrate patient and worker

safety activities across departments and programs.

• Build and raise awareness of linkages and cross-

cutting topic areas.

• Recognize shared health and safety risks between

health care staff and patients.

• Align patient and worker safety improvement initia-

tives having common goals. Consider integrating with

organizational quality improvement priorities.

• Convene multidisciplinary safety committees that

include representation from patient safety, employee

health, occupational/environmental safety and health,

infection prevention, risk management, human

resources, and other areas.

• Examine policies for their impact (positive or negative)

and unintended consequences on worker and patient

safety.

• Remove structural and functional organizational sys-

tems and processes that maintain traditional “silos” for

patient and worker health and safety.

• Develop a business case for integrating patient and

worker safety initiatives; calculate a cost-benefit

analysis or return on investment for specific initiatives.

Understand and measure performance on safety-related

issues.

• Learn about evidence-based practices from published

literature, conferences, networking, and other

sources. Information sources should cross multiple

disciplines. Incorporate and tailor relevant practices to

your setting. Address obstacles and lessons learned

by others in the field.

• Understand your risks based on facts—not percep-

tion. Gather baseline data on your current safety per-

formance for benchmarking future performance.

Monitor performance over time.

• Conduct periodic hazard analyses.

• Examine data from manual and automated employee

and patient incident reporting systems (for example,

work-related injury and illness incidence reports, haz-

ard inspections, environmental hazards, patient safety

incidents, medication errors, infection prevention), as

well as quality improvement and performance meas-

urement systems (internal and external) and human

resources information (such as satisfaction surveys,

turnover, absenteeism) to identify patterns and trends.

• Develop and improve nonpunitive incident reporting

systems and encourage reporting for safety incidents,

hazards, errors, and near misses.

• Investigate worker and patient safety events, errors,

and near misses using root cause and other analysis

tools to understand and identify contributing factors.

Implement and maintain successful worker and patient

safety improvement initiatives.

• Develop a work plan, time line, staff accountabilities,

and measures of success.

• Begin with small-scale changes to demonstrate suc-

cess, then spread to other areas as enthusiasm

builds.

• Develop employee training curricula and educational

resources. Implement initial and regular training for

new and existing staff. Enhance traditional educa-

tional methods with experiential, simulation, and sce-

nario training.

• Redesign processes and systems based on identifica-

tion of root causes and contributing factors to prevent

future events.

• Integrate changes into existing process and proce-

dures when possible.

Chapter 4: Patient and Worker Safety Synergies—Key Themes and Action Steps to Meet Challenges and Achieve Success

program called the National Occupational Research Agenda

to stimulate innovative research and improved workplace

practices in occupational safety and health. Subsequently,

NIOSH and its partners formed 10 Sector Councils aligned

to major industry groups including Healthcare and Social

Assistance (HCSA). The Sector Councils developed

industry-specific research agendas for the nation. Prior to

developing its research agenda, the Healthcare and Social

Assistance Sector Council had developed a compendium

(http://www.cdc.gov/niosh/docs/2009-139/) comprising

reviews of topic-specific chapters on known evidence,

emerging issues, knowledge gaps, and research needs. This

“state of the sector” compendium was used to develop the

HCSA research agenda and also served as a primary source

of information for this monograph. Intended to be ever-

green, the HCSA research agenda can be found at

http://www.cdc.gov/niosh/programs/hcsa/goals.html.

In the course of developing this monograph, a number of

research opportunities were also identified. Overall, we

found there was very little empirical research on the syner-

gies between patient and worker safety and a dearth of rig-

orous studies upon which an evidence base could be

established. The opportunities to examine current safety

practices, safety culture, organization performance, and

patient and worker outcomes are vast and evolving.

Examples of research topic areas and future activities that

would help build consensus around the value of integrating

patient and worker safety are listed in Sidebar 4-2, page 134.

Federal funding for research in this area has typically been

provided by two disparate agencies. NIOSH, a part of the

Centers for Disease Control, is the federal agency responsi-

ble for conducting research and making recommendations

for the prevention of work-related injury and illness. The

Agency for Healthcare Research and Quality (AHRQ), with

its mission to improve the quality, safety, efficiency, and

effectiveness of health care for all Americans, supports

research that helps people make more informed decisions

and improves the quality of health care services. AHRQ has

supported several large initiatives examining safety culture,

work environment, and patient outcomes. The interdiscipli-

nary nature of the safety research described in this mono-

graph suggests the need for interagency collaboration and

public-private partnerships to support research efforts to

advance the evidence base for improving safety for both

patients and workers.

4.2 Conclusion

The purpose of this monograph is to stimulate greater

awareness of the potential synergies between patient and

worker health and safety activities. Toward that end, we

have presented a wide range of case examples, tools, tech-

niques, and resources for further information on topic areas

that are common across patient and worker safety.

It is worthwhile to review a few of the key points and les-

sons that can be drawn overall from the monograph. The

growing evidence that employee well-being affects patient

safety, both directly and indirectly, suggests that healthcare

organizations striving for high reliability should be con-

cerned with safety for both patients and workers. Leaders

determine the extent to which the organization has a strong

safety culture and positive work environment. There are

numerous topic areas and examples of improvement inter-

ventions that can simultaneously benefit patients, employ-

ees, and the health care organization as a whole. These

improvements can be applied not only in hospitals but also

in home care, nursing homes, behavioral health, and several

other settings.

Opportunities for functional synergies and collaboration on

patient and worker safety exist in the areas of adverse event

and hazard surveillance, reporting, analysis, and feedback;

safety management systems; human factors and ergonomics;

safer design of work processes and the built environment;

and strategies to enhance communication and support staff

engagement in improvement activities. The case examples

describe challenges and strategies for overcoming obstacles

in the areas of bariatric safe patient handling, fall preven-

tion, violence prevention and mitigation, clinician support

following unanticipated clinical events, as well as more gen-

eral topics such as improving the civility of staff interac-

tions, perceptions of safety, and moving toward becoming a

high reliability organization.

133

• Identify and develop frontline worker “champions” who

support and guide employees and promote the initia-

tive’s success.

• Use visual, auditory, and electronic reminders to keep

staff engaged.

• Provide regular feedback on overall and unit-level

safety to staff.

• Post progress as visible recognition of success (for

example, posters, intranet systems)

• Recognize and reward employee efforts to improve

patient and worker safety.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

This monograph represents only a starting point for what

should become an ongoing effort to further our under-

standing of the value, benefits, and challenges of an inte-

grated approach to patient and worker safety. Through

research, practical experience, and sharing of information,

we will learn how best to prevent adverse events, reduce

harm, and improve outcomes for all.

134

Sidebar 4-2: Research

Opportunities to Help Integrate

Patient and Worker Safety

Examples of research topic areas and future activities

that would help build consensus around the value of inte-

grating patient and worker safety include the following:

• Studies of the relationships between patient and

worker safety and health risks and outcomes

• Development of evidence-based guidelines or prac-

tice recommendations on the impact of worker safety

on patient and worker outcomes through systematic

literature review, expert consensus panels, and

research conferences

• Demonstrations of return on investment for integrated

patient and worker safety initiatives

• Development of improved safety and injury surveil-

lance systems, with alerts that help identify patient

and occupational safety events across health care

settings

• Assessment of the value of nonpunitive error and near-

miss reporting within organizations and at the national

level to identify causes and contributing factors

• Exploration of commonalities and effective strategies

for measurement of patient and worker safety culture

and worker and patient satisfaction in health care

organizations

• Studies of workforce staffing practices (for example,

shift length, shift rotation, overtime, staff skill mix, and

coverage) and their relationship to health and safety

outcomes for workers and patients

• Evaluation of benefits and effectiveness of mechani-

cal lifting devices in preventing worker MSDs and

patient injuries outside the hospital setting

• Identification of hazard elimination options for safety

risks (for example, patient lifting and transfer, sharps

injuries, injuries related to slips, trips, and falls)

• Effectiveness of facility design approaches that

reduce safety risks and promote a healthy work envi-

ronment (for example, reduction of slips, trips, and

falls; strategic placement of hand hygiene stations;

appropriate lighting and ventilation)

• Development of a toolkit to support integration of

worker and patient safety practice within health care

organizations

• Development of standardized metrics or performance

measures useful in assessing the effectiveness of

interventions and assessing outcomes for integrated

improvement efforts both within and across organiza-

tions

• Implementation of a centralized resource site or portal

to collect and share ideas and best practices among

health care organizations and other stakeholders

• Development of methodologies to share data between

health care organizations and external agencies

• Consensus on standardized definitions and data ele-

ments for common terms (for example, falls, assaults)

that can be used for patient and worker incident

reporting

• Implementation of learning collaboratives for

patient–worker safety synergies

OSHA Topics Matched to

Joint Commission Standards

January 2012

Note: Standards are from Joint Commission’s Comprehensive Accreditation Manual for Hospitals, 2012 edition.

Those labeled EC refer to the Environment of Care chapter; IC refer to the Infection Prevention and Control chapter; IM refer to the

Information Management chapter; LD refer to the Leadership chapter; LS refer to the Life Safety chapter; MM refer to the Medication

Management chapter; PI refer to the Performance Improvement chapter.

135

– Appendix A –

OSHA Topics Matched to Joint Commission Standards January 2012

OSHA Topics Joint Commission Standards

Voluntary Protection

Program (VPP)

HR.01.01.01 The hospital has the necessary staff to support the care, treatment, and services it

provides.

HR.01.06.01 Staff are competent to perform their responsibilities.

EC.03.01.01 Staff and licensed independent practitioners are familiar with their roles and responsi-

bilities relative to the environment of care.

PI.01.01.01 The hospital collects data to monitor its performance.

PI.02.01.01 The hospital compiles and analyzes data.

PI.03.01.01 The hospital improves performance on an ongoing basis.

EC.04.01.01 The hospital collects information to monitor conditions in the environment.

EC.04.01.03 The hospital analyzes identified environment of care issues.

EC.04.01.05 The hospital improves its environment of care.

LD.03.01.01 Leaders create and maintain a culture of safety and quality throughout the hospital.

LD.03.02.01 The hospital uses data and information to guide decisions and to understand varia-

tion in the performance of processes supporting safety and quality.

LD.03.03.01 Leaders use hospitalwide planning to establish structures and processes that focus

on safety and quality.

LD.03.04.01 The hospital communicates information related to safety and quality to those who

need it, including staff, licensed independent practitioners, patients, families, and

external interested parties.

LD.03.05.01 Leaders implement changes in existing processes to improve the performance of the

hospital.

LD.03.06.01 Those who work in the hospital are focused on improving safety and quality.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

136

OSHA Topics Matched to Joint Commission Standards January 2012

OSHA Topics Joint Commission Standards

Bloodborne

pathogens, TB

IC.02.01.01 The hospital implements its infection prevention and control plan.

IC.02.03.01 The hospital works to prevent the transmission of infectious disease among patients,

licensed independent practitioners, and staff.

Ventilation

EC.02.05.01 The hospital manages risks associated with its utility systems.

EC.02.05.05 The hospital inspects, tests, and maintains utility systems.

EC.02.02.01 The hospital manages risks related to hazardous materials and waste.

EC.02.06.05 The hospital manages its environment during demolition, renovation, or new con-

struction to reduce risk to those in the organization.

Information

management

IM entire chapter

EC.04.01.01 The hospital collects information to monitor conditions in the environment.

EC.04.01.03 The hospital analyzes identified environment of care issues.

PI.01.01.01 The hospital collects data to monitor its performance.

PI.02.01.01 The hospital compiles and analyzes data.

LD.03.02.01 The hospital uses data and information to guide decisions and to understand varia-

tion in the performance of processes supporting safety and quality.

Patient handling,

lifting, and moving

EC.03.01.01 Staff and licensed independent practitioners are familiar with their roles and responsi-

bilities relative to the environment of care.

EC.04.01.01 The hospital collects information to monitor conditions in the environment.

EC.04.01.03 The hospital analyzes identified environment of care issues.

Safety and health

programs

EC.02.01.01 The hospital manages safety and security risks.

EC.03.01.01 Staff and licensed independent practitioners are familiar with their roles and responsi-

bilities relative to the environment of care.

EC.04.01.01 The hospital collects information to monitor conditions in the environment.

EC.04.01.03 The hospital analyzes identified environment of care issues.

EC.04.01.05 The hospital improves its environment of care.

Workplace violence

EC.02.01.01 The hospital manages safety and security risks.

EC.03.01.01 Staff and licensed independent practitioners are familiar with their roles and responsi-

bilities relative to the environment of care.

Hazardous drugs,

reproductive hazards,

and anesthetic gases

EC.02.02.01 The hospital manages risks related to hazardous materials and waste.

MM.01.01.03 The hospital safely manages high-alert and hazardous medications.

Appendix A: OSHA Topics Matched to Joint Commission Standards

137

OSHA Topics Matched to Joint Commission Standards January 2012

OSHA Topics Joint Commission Standards

Laboratory

and hazard

communication

EC.02.02.01 The hospital manages risks related to hazardous materials and waste.

EC.03.01.01 Staff and licensed independent practitioners are familiar with their roles and responsi-

bilities relative to the environment of care.

Ethylene oxide,

formaldehyde, glu-

taraldehyde, nitrous

oxide, and other haz-

ardous vapors, includ-

ing those vapors

generated while using

cauterizing equipment

and laser

EC.02.02.01 The hospital manages risks related to hazardous materials and waste.

EC.02.04.03 The hospital inspects, tests, and maintains medical equipment.

EC.02.05.01 The hospital manages risks associated with its utility systems.

EC.02.05.05 The hospital inspects, tests, and maintains utility systems.

OSHA record keeping

EC.04.01.01 The hospital collects information to monitor conditions in the environment.

EC.02.02.01 The hospital manages risks related to hazardous materials and waste.

Walking and

working surfaces

EC.02.01.01 The hospital manages safety and security risks.

EC.04.01.01 The hospital collects information to monitor conditions in the environment.

EC.04.01.03 The hospital analyzes identified environment of care issues.

EC.04.01.05 The hospital improves its environment of care.

Fire safety

EC.02.03.01 The hospital manages fire risks.

EC.02.03.03 The hospital conducts fire drills.

EC.02.03.05 The hospital maintains fire safety equipment and fire safety building features.

LS.01.02.01 The hospital protects occupants during periods when the Life Safety Code is not met

or during periods of construction.

Electrical safety

EC.02.05.01 The hospital manages risks associated with its utility systems.

EC.03.01.01 Staff and licensed independent practitioners are familiar with their roles and responsi-

bilities relative to the environment of care.

Education/profes-

sional qualifications

of parties responsi-

ble for the safety and

health program

HR.01.02.01 The hospital defines staff qualifications.

HR.01.02.05 The hospital verifies staff qualifications.

HR.01.05.03 Staff participate in ongoing education and training.

HR.01.06.01 Staff are competent to perform their responsibilities.

EC.03.01.01 Staff and licensed independent practitioners are familiar with their roles and responsi-

bilities relative to the environment of care.

Safety and health

statistics MSDS and

OSHA 300 log

EC.04.01.01 The hospital collects information to monitor conditions in the environment.

EC.04.01.03 The hospital analyzes identified environment of care issues.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

138

Glossary of Terms

Abuse: Intentional mistreatment that may cause

either physical or psychological injury. See also mental

abuse, physical abuse, and sexual abuse.

American National Standards Institute

(ANSI): A privately funded voluntary membership

organization that develops consensus standards nation-

ally for a wide variety of devices and procedures.

Behavioral health care: A broad array of care,

treatment, or services for individuals with mental

health issues or problems, foster care needs, addictive

behaviors, chemical dependency issues, or intellectual

disabilities. Care, treatment, or services can be pro-

vided in a wide variety of settings, such as

inpatient/crisis stabilization, residential, day program,

and outpatient settings.

Behaviors that undermine a culture of

safety: Conduct by staff working in the organization

that intimidates others to the extent that quality and

safety could be compromised. These behaviors, as

determined by the organization, may be verbal or

nonverbal, may involve the use of rude language, may

be threatening, or may involve physical contact.

Best practices: Clinical, scientific, or professional

practices that are recognized by a majority of profes-

sionals in a particular field. These practices are typi-

cally evidence based and consensus driven.

Biohazard: A combination of the words biological

and hazard; organisms or products of organisms that

present a risk to humans.

Bloodborne pathogens: Pathogenic microorgan-

isms that may be present in human blood and can

cause disease in humans. These pathogens include but

are not limited to hepatitis B virus (HBV), hepatitis C

virus (HCV), and human immunodeficiency virus

(HIV).

Bureau of Labor Statistics (BLS): The Bureau

of Labor Statistics of the U.S. Department of Labor is

the principal Federal agency responsible for measuring

labor market activity, working conditions, and price

changes in the economy. Its mission is to collect, ana-

lyze, and disseminate essential economic information

to support public and private decision-making. As an

independent statistical agency, BLS serves its diverse

user communities by providing products and services

that are objective, timely, accurate, and relevant.

(http://www.bls.gov/bls/infohome.htm)

Carcinogen: A substance or agent capable of caus-

ing or producing cancer in mammals, including

humans. A chemical is considered to be a carcinogen

if: (a) it has been evaluated by the International

Agency for Research on Cancer (IARC) and found to

be a carcinogen or potential carcinogen; or (b) it is

listed as a carcinogen or potential carcinogen in the

Annual Report on Carcinogens published by the

National Toxicology Program (NTP) (latest edition);

or (c) it is regulated by OSHA as a carcinogen.

Clinical practice guidelines: Tools that describe

a specific procedure or processes found, through clini-

cal trials or consensus opinion of experts, to be the

most effective in evaluating and/or treating a patient,

resident, or individual served who has a specific

symptom, condition, or diagnosis. Synonyms include

practice parameter, protocol, clinical practice

recommendations, preferred practice pattern, and

guideline.

139

– Appendix B –

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Close call (or “near miss”):

Any process variation that

did not affect an outcome but for which a recurrence carries

a significant chance of a serious adverse outcome. Such

events fall within the scope of the definition of a sentinel

event but outside the scope of those sentinel events that are

subject to review by The Joint Commission under its

Sentinel Event Policy.

Continuity: The degree to which the care of individuals is

coordinated among health care professionals, among organi-

zations, and over time.

Culture of safety: Characterized by open and respectful

communication among all members of the health care team

in order to provide safe patient care. It is a culture that sup-

ports “organizational commitment to continually seeking to

improve safety.”

Days away, restricted, or transferred (DART): A

calculation based on (N

x EH) x (200,000), where N is the

number of cases involving days away and/or restricted work

activity and/or job transfer; EH is the total number of hours

worked by all employees during the calendar year; and

200,000 is the base number of hours worked for 100 full-

time equivalent employees.

Disruptive behavior: Behavior that interferes with effec-

tive communication among health care providers and nega-

tively impacts performance and outcomes. Behavior that is

not supportive of a culture of safety.

Environmental tours: Activities routinely used by the

organization to determine the presence of unsafe conditions

and whether the organization’s current processes for manag-

ing environmental safety risks are practiced correctly and are

effective.

Epidemic: A disease, such as influenza, that spreads rap-

idly, attacks many people in a geographic area, causes a high

rate of morbidity or mortality, and then subsides. Epidemic

applies especially to infectious diseases, as in an epidemic of

cholera, but it is also applied to any disease, injury, or other

health-related event, such as an epidemic of teenage suicide.

Equipment management: Activities selected and imple-

mented by the organization to assess and control the clinical

and physical risks of fixed and portable equipment used for

diagnosis, treatment, monitoring, and care.

Fear eliciting: Intentionally causing undue fear, fright,

panic, or terror in order to obtain compliance by the indi-

vidual.

Fire-safety management: Activities selected and imple-

mented by the organization to assess and control the risks of

fire, smoke, and other byproducts of combustion that could

occur during the organization’s provision of care, treatment,

or services.

Hazard: A source of risk that does not necessarily imply

potential for occurrence. A hazard produces risk only if an

exposure pathway exists and if exposures create the possibil-

ity of adverse consequences.

Hazardous materials and waste: Materials whose

handling, use, and storage are guided or defined by local,

state, or federal regulation, such as OSHA’s Regulations for

Bloodborne Pathogens regarding the disposal of blood and

blood-soaked items and the Nuclear Regulatory

Commission’s regulations for the handling and disposal of

radioactive waste. This term also includes hazardous vapors

(for example, glutaraldehyde, ethylene oxide, nitrous oxide)

and hazardous energy sources (for example, ionizing or non-

ionizing radiation, lasers, microwave, ultrasound). Although

The Joint Commission considers infectious waste as falling

into this category of materials, federal regulations do not

define infectious or medical waste as hazardous waste.

Health care–associated infection (HAI): An infec-

tion acquired concomitantly by an individual who is receiv-

ing or who has received care, treatment, or services from a

health care organization. The infection may or may not have

resulted from the care, treatment, or services.

HEPA (High-Efficiency Particulate Air) filter: A dis-

posable, extended medium, dry type filter with a particle

removal efficiency of no less than 99.97 percent for 0.3m

particles.

High reliability organization (HRO): Systems operat-

ing in hazardous conditions that have fewer than their fair

share of adverse events.

High risk procedures or processes: A procedure or

process that, if not planned and/or implemented correctly,

has a significant potential for affecting the safety of a patient

or an individual served.

140

Appendix B: Glossary of Terms

Horizontal violence (horizontal hostility):

Physical,

verbal, or emotional abuse of an employee. Within nursing,

lateral violence has been defined as nurse-to-nurse aggres-

sion. This violence can be manifested in verbal or nonverbal

behaviors.

Infection: The transmission of a pathogenic microorgan-

ism to a host, with subsequent invasion and multiplication,

with or without resulting symptoms of disease.

Invasive procedure: The puncture or incision of the

skin, insertion of an instrument, or insertion of foreign

material into the body for diagnostic or treatment-related

purposes. Examples of invasive procedures include central

line and chest tube insertions and cardiac catheterization.

Venipuncture is not categorized as an invasive procedure.

Lateral violence: See Horizontal violence.

Life Safety Code

: A set of standards for the construc-

tion and operation of buildings intended to provide a rea-

sonable degree of safety during fires. These standards are

prepared, published, and periodically revised by the

National Fire Protection Association and adopted by The

Joint Commission to evaluate health care organizations

under its life safety management program.

Maintenance: There are five types of maintenance—pre-

dictive, metered, corrective, interval based, and reliability

centered: (1) Predictive maintenance is a type of mainte-

nance strategy that provides the means to achieve reliability

levels that exceed the performance of a piece of equipment

or system. This strategy is designed to measure and track

data significant to the piece of equipment or system. It con-

firms possible faults with the equipment, and specific repairs

are completed before the equipment fails. Predictive analysis

can be performed using advanced monitoring instruments

and predictive software that collects data and performs an

analysis. The data collected are analyzed, and corrective

maintenance is performed when the equipment is perform-

ing outside the desired operating parameters. (2) Metered

maintenance strategy is based on the hours of run time or

the number of times the equipment is used (for example,

number of images processed). (3) Corrective maintenance

strategy restores a piece of equipment to operational status

after equipment failure. (4) Interval-based maintenance is

done according to specific intervals (for example, calendar

time, running hours). A number of periodic inspections or

restoration tasks are completed based on information/data

obtained from the last equipment check. (5) Reliability-

centered maintenance is a type of maintenance that begins

with a failure mode and effects analysis to identify the criti-

cal equipment failure modes in a systematic and structured

manner. The process then requires the examination of each

critical failure mode to determine the optimum mainte-

nance policy to reduce the severity of each failure. The cho-

sen type of maintenance strategy must take into account

cost, safety, and environmental and operational conse-

quences. Some functions are not critical and may be allowed

to “run to failure,” while other functions must be preserved

at all cost. Reliability-centered maintenance emphasizes the

use of predictive maintenance techniques in addition to tra-

ditional preventive measures (metered, corrective, and inter-

val based).

Management system: Major elements of an effective

occupational safety and health management system include

the following four aspects: management commitment and

employee involvement; worksite analysis; hazard prevention

and control; and safety and health training.

Measure of Success (MOS): A numeric or otherwise

quantifiable measure usually related to an audit that deter-

mines whether an action was effective and sustained.

Medical device: An instrument, apparatus, implement,

machine, contrivance, implant, in vitro reagent, or another

similar or related article, including a component part or

accessory that is (1) recognized in the official National

Formulary or the US Pharmacopeia or any supplement to

them; (2) intended for use in the diagnosis of disease or

other conditions or in the cure, mitigation, treatment, or

prevention of disease in humans or other animals; or (3)

intended to affect the structure or any function of the body

of humans or other animals and that does not achieve any

of its primary intended purposes through chemical action

within or on the body of humans or other animals and that

is not dependent on being metabolized for the achievement

of any of its primary intended purposes.

Medical equipment: Fixed and portable equipment used

for the diagnosis, treatment, monitoring, and direct care of

individuals.

Medical staff: The group of all licensed independent

practitioners and other practitioners privileged through the

organized medical staff process that is subject to the medical

staff bylaws. This group may include others such as retired

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Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

practitioners who no longer practice in the organization but

who wish to continue their membership in the group, cour-

tesy staff, scientific staff, and so forth.

Medication error: A preventable event that may cause or

lead to inappropriate medication use or patient harm while

the medication is in the control of the health care profes-

sional, patient, or consumer. Such events may be related to

professional practice, health care products, procedures, and

systems, including prescribing; order communication; prod-

uct labeling, packaging, and nomenclature; compounding;

dispensing; distribution; administration; education; moni-

toring; and use.

Mental abuse: Intentional mistreatment of an individual

that may cause psychological injury. Examples include

humiliation, harassment, exploitation, and threats of pun-

ishment or deprivation.

National Center for Health Statistics (NCHS): A

center within the CDC that is responsible for the collection,

analysis, and dissemination of health statistics. NCHS has

two major types of data systems: those based on population

data collected through personal interviews or examinations

and systems based on individual records, with data collected

from state and local vital and medical records.

National Center for Infectious Disease (NCID): A

center in the CDC whose mission is to prevent illness, dis-

ability, and death caused by infectious diseases in the United

States and around the world. NCID accomplishes its mis-

sion by conducting surveillance, epidemic investigations,

epidemiologic and laboratory research, training, and public

education programs to develop, evaluate, and promote pre-

vention and control strategies for infectious diseases.

National Center for Injury Prevention and Control

(NCIPC): A center in the CDC whose mission is to reduce

morbidity, disability, mortality, and costs associated with

non-occupational injuries.

National Electronic Injury Surveillance System

(NEISS): A data system maintained by the Consumer

Product Safety Commission (CPSC) to monitor consumer

product-related injuries, representing a national sample of

US Emergency departments. In an interagency agreement

with NIOSH, NEISS also collects and codes data on all

work-related injuries from emergency departments regardless

of consumer product involvement.

National Health Interview Survey (NHIS): A cross-

sectional household interview survey by the National Center

for Health Statistics (NCHS), which is a principal source of

information on the health of the US civilian population.

NHIS data are used to monitor trends in illness, injury, and

disability and to track progress toward achieving national

health objectives.

National Occupational Research Agenda (NORA):

A NIOSH-sponsored partnership program to stimulate

innovative research and improved workplace practices.

Unveiled in 1996, NORA has become a research framework

for NIOSH and the nation. The program entered its second

decade in 2006 with a new industry sector–based structure

to better move research to practice within workplaces.

Health care and social assistance is one of the 10 industry

sectors.

National Institute for Occupational Safety and

Health (NIOSH): A federal agency responsible for con-

ducting research and making recommendations for the pre-

vention of work-related injury and illness. NIOSH is part of

the Centers for Disease Control and Prevention in the

Department of Health and Human Services.

Nursing staff: Personnel within an organization who are

accountable for providing and assisting in the provision of

nursing care. Such personnel must include registered nurses

(RNs), and may include others such as advanced practice

registered nurses (APRNs), licensed practical or licensed

vocational nurses (LPNs/LVNs), and nursing assistants or

other designated unlicensed assistive personnel.

Orientation: A process used to provide initial training and

information while assessing the competence of clinical staff

relative to job responsibilities and the organization’s mission

and goals.

OSHA: The Occupational Safety and Health

Administration is a federal agency in the Department of

Labor responsible for developing and enforcing safety and

health regulations and providing training, outreach, educa-

tion, and assistance.

Outbreak: The occurrence of more than the expected

number of cases of disease, injury, or other health condi-

tions among a specific group during a specified time

frame.

142

Appendix B: Glossary of Terms

Outcome measure:

A tool used to assess data that indi-

cates the results of performance or nonperformance of a

function or procedure.

Patient: An individual who receives care, treatment, or

services. Synonyms used by various health care fields include

resident, patient and family unit, individual served, consumer,

health care consumer, customer, and beneficiary.

Performance improvement: The systematic process of

detecting and analyzing performance problems, designing

and developing interventions to address the problems,

implementing the interventions, evaluating the results, and

sustaining improvement.

Performance measurement system: A method of

gauging organization performance that facilitates improve-

ment through the collection of data and information and

the dissemination of process and/or outcome measures over

time.

Personal protective equipment (PPE): Devices worn

by a health care worker to protect against hazards in the

environment. Examples include respirators, gloves, and

hearing protectors.

Physical abuse: Intentional mistreatment of an individ-

ual that may cause physical injury. Examples include hitting,

slapping, pinching, or kicking, and may also include

attempts to control behavior through corporal punishment.

Prevention effectiveness: A process to evaluate the

effectiveness of prevention activities. These assessments use

decision analysis, meta-analysis, economic analysis, and

other methods to determine the effect of prevention pro-

grams on public health.

Quality of care, treatment, and services: The

degree to which care, treatment, or services for individuals

and populations increases the likelihood of desired health

or behavioral health outcomes. Considerations include the

appropriateness, efficacy, efficiency, timeliness, accessibil-

ity, and continuity of care; the safety of the care environ-

ment; and the individual’s personal values, practices, and

beliefs.

Quantitative result: A test result that is measured as a

discrete number.

Teach-back (read-back): A method used to ensure

understanding of information that is communicated, often

between members of a caregiving team. The process involves

an individual receiving verbal information (such as an order

or a test result), recording the complete information, and

then reading back and confirming the information to the

individual who provided the information.

Reassessment: Ongoing data collection, which begins

on initial assessment, comparing the most recent data with

the data collected at earlier assessments.

Respirator: A device worn over an individual’s face that is

designed to reduce the wearer’s exposure to airborne con-

taminants. Respirators come in various sizes and must be

individually selected to provide a tight seal over the face. A

proper seal between the user’s face and the respirator forces

inhaled air to be pulled through the respirator’s filter mate-

rial and not through gaps between the face and respirator.

Where workers are required by employers to wear respira-

tors, they must be NIOSH-certified, selected, and used in

the context of a comprehensive respiratory protection pro-

gram, (see OSHA standard 29 CFR 1910.134, or

http://www.osha.gov/SLTC/respiratoryprotection/index

.html).

Risk: The probability that a disease, injury, condition,

death, or related occurrence may occur for a person or

population.

Risk assessment, proactive: An assessment that exam-

ines a process in detail including sequencing of events,

actual and potential risks, and failure or points of vulnera-

bility and that prioritizes, through a logical process, areas for

improvement based on the actual or potential impact (that

is, criticality) of care, treatment, or services provided.

Root cause analysis (RCA): A process for identifying a

basic or causal factor(s) underlying variation in perform-

ance, including the occurrence or possible occurrence of a

sentinel event.

Safety: The degree to which the risk of an intervention

(for example, use of a drug, or a procedure) and risk in the

care environment are reduced for a patient and other per-

sons, including health care practitioners. Safety risks may

arise from the performance of tasks relating to the structure

of the physical environment or from situations beyond the

organization’s control (such as weather).

143

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Safety management:

Activities selected and implemented

by the organization to assess and control the impact of envi-

ronmental risk and improve general environmental safety.

Secure: Safety within a locked container, in a locked

room, or under constant surveillance.

Security: Protection of people and property against harm

or loss (for example, workplace violence, theft, access to

medications). Security incidents may be caused by persons

from outside or inside the organization.

Sentinel event: An unexpected occurrence involving

death or serious physical or psychological injury or the risk

thereof. The phrase “or the risk thereof” includes any

process variation for which a recurrence would carry a sig-

nificant chance of a serious adverse outcome.

Sentinel Event Notification Systems for

Occupational Risks (SENSOR): A NIOSH cooperative

agreement program with state health departments, or other

state agencies in collaboration with state health depart-

ments, which develops generalizable condition-specific

strategies for state-based surveillance of occupational diseases

and injuries. Efforts have focused upon standardization of

variables collected by the state programs, creation of soft-

ware to facilitate adoption of the surveillance systems by

additional states, comparison of SENSOR findings to other

surveillance data sources, collaboration with The Council of

State and Territorial Epidemiologists (CSTE) on building

infrastructure for state-based surveillance, further develop-

ment of state-based hazard surveillance, and publication and

dissemination of SENSOR reports. A key focus of the SEN-

SOR program is to enhance the linkage between surveil-

lance and intervention.

Sexual abuse: Intentional mistreatment of a sexual

nature of an individual that may cause physical and/or psy-

chological injury. Synonyms include sexual harassment, sex-

ual coercion, and sexual assault.

Staff: As appropriate to their roles and responsibilities, all

people who provide care, treatment, or services in the organ-

ization, including those receiving pay (for example, perma-

nent, temporary, and part-time personnel, as well as

contract employees), volunteers, and health profession stu-

dents. The definition of staff does not include licensed inde-

pendent practitioners who are not paid staff or who are not

contract employees.

Standard: A principle of patient safety and quality of care

that a well-run organization meets. A standard defines the

performance expectations, structures, or processes that must

be substantially in place in an organization to enhance the

quality of care, treatment, or services.

Surgical mask: Surgical masks are used as a physical bar-

rier to protect the user from hazards, such as contact with

large droplets of blood or body fluids. Surgical masks also

protect other people against infection from the person wear-

ing the surgical mask. Such masks trap large particles of

body fluids that may contain bacteria or viruses expelled by

the wearer. Surgical masks are used for several different pur-

poses, including the following:

– Placed on sick people to limit the spread of infec-

tious respiratory secretions to others.

– Worn by health care providers to prevent accidental

contamination of patients’ wounds by the organisms

normally present in mucus and saliva.

– Worn by workers to protect themselves from splashes

or sprays of blood or bodily fluids; they may also

keep contaminated fingers/hands away from the

mouth and nose.

Surveillance: The ongoing systematic collection, analysis,

and interpretation of data concerning the frequency or pattern

of, and causes or factors associated with, a given disease, injury,

or other health condition. Data analysis is followed by the dis-

semination of that information to those who can improve out-

comes. Examples of surveillance data can include ventilator-

associated pneumonia, antibiotic prophylaxis, hemodialysis

catheter infections, implant infections, surgical-site infections,

hand hygiene, drug-resistant organisms (MRSA, VRE), equip-

ment sterile processing, vaccinations, urinary tract infections,

and health care worker immunization.

Synergy: A mutually advantageous conjunction or com-

patibility of distinct business participants or elements.

The Joint Commission: An independent, not-for-profit

organization dedicated to improving the safety and quality

of health care through standards development, public policy

initiatives, accreditation, and certification. The Joint

Commission accredits and certifies more than 19,000 health

care organizations and programs in the United States.

Time-out, invasive procedure: An immediate pause by

the entire surgical team to confirm the correct patient, pro-

cedure, and surgical site.

144

Appendix B: Glossary of Terms

Tracer methodology:

A process surveyors (The Joint

Commission) use during the on-site survey to analyze an

organization’s systems, with particular attention to identified

priority focus areas, by following an individual patient, resi-

dent, or individual served through the organization’s care

process in the sequence experienced by each individual.

Depending on the setting, this process may require survey-

ors to visit multiple care programs and services within an

organization or within a single program or service to “trace”

the care rendered.

Transmission-based precautions: Infection preven-

tion and control measures to protect against exposure to a

suspected or identified pathogen. These precautions are spe-

cific and based on the way the pathogen is transmitted.

Categories include contact, droplet, airborne, and a combi-

nation of these.

Voluntary Protection Program (VPP): A program

offered by OSHA that recognizes employers and workers in

private industry and federal agencies who have implemented

effective safety and health management systems and main-

tain injury and illness rates below national averages for their

respective industries. In VPP, management, labor, and

OSHA work cooperatively and proactively to prevent fatali-

ties, injuries, and illnesses through a system focused on haz-

ard prevention and control; worksite analysis; training; and

management commitment and worker involvement. To par-

ticipate, employers must submit an application to OSHA

and undergo a rigorous on-site evaluation by a team of

safety and health professionals. Union support is required

for applicants represented by a bargaining unit. VPP partici-

pants are reevaluated every three to five years to remain in

the programs. VPP participants are exempt from OSHA-

programmed inspections while they maintain their VPP

status.

Workarounds: As described by Halbesleben et al., 2008,

workarounds are alternative, informally designed, and

inconsistently applied work processes that expedite work

flow but sometimes subvert specific safeguards to prevent

efforts that can impact patients and/or workers.

Workplace bullying: Repeated inappropriate behavior,

direct or indirect, whether verbal, physical or otherwise,

conducted by one or more persons against another or oth-

ers, at the place of work and/or in the course of employ-

ment, which could reasonably be regarded as undermining

the individual’s right to dignity at work.

Workplace violence: Violent acts (including physical

assaults and threats of assaults) directed toward persons at

work or on duty. Workplace violence, ranging from offen-

sive or threatening language to homicide, can be divided

into four categories, including violence by strangers, clients

(patients), coworkers, and personal relations.

—All definitions not otherwise indicated are based on The

Joint Commission’s Comprehensive Accreditation Manual for

Hospitals Glossary, 2012.

References

1 Occupational Safety and Health Administration [Internet]. 1996

May [cited 2012 Jan 31]. Construction Safety and Health

Outreach Program; [about 5 screens]. Available from:

http://www.osha.gov/doc/outreachtraining/htmlfiles/hazglos.html.

2 Centers for Disease Control and Prevention [Internet]. [updated

2009 Aug 26; cited 2012 Jan 31]. NHSN Blood/Body Fluid

Exposure Module; [about 50 p.]. Available from:

http://www.cdc.gov/nhsn/PDFs/HPS/training/HPS_BloodBody

FluidExposure_cleared_revrp_tm.pdf.

3 Institute of Medicine. Preventing Medication Errors. Washington

(DC): The National Academies Press; 2007. p. 15.

4 Safex [Internet]. [cited 2012 Jan 31]. DART rate; [about 1 p.].

Available from: http://www.safex.us/_data/resource/DART%20

Rate.pdf.

5 Center for American Nurses [Internet]. Silver Spring (MD):

Center for American Nurses; c2008 [updated 2008 Feb; cited

2012 Jan 30]. Policy Statement on Lateral Violence and Bullying

in the Workplace; [about 12 p.]. Available from: http://center

foramericannurses.org/associations/9102/files/Position%20

StatementLateral%20Violence%20and%20Bullying.pdf.

6 Occupational Safety and Health Administration [Internet]. [cited

2012 Jan 31]. About OSHA; [about 1 screen]. Available from:

http://www.osha.gov/about.html.

7 Reason J. Human Error: Models and Management. BMJ

2000;320:768–770.

8 Occupational Safety and Health Administration [Internet]. OSHA

Fact Sheet: Voluntary Safety and Health Program Management

Guidelines; [about 2 p.]. Available from: http://www.osha.gov

/OshDoc/data_General_Facts/vol_safetyhealth_mngt_.pdf.

9 The National Occupational Research Agenda (NORA) [Internet].

[updated 2012 Jun 12; cited Jul 25]. About NORA...Partnerships,

Research and Practice; [about 1 screen]. Available from:

http://www.cdc.gov/niosh/nora/about.html.

10 Boiano J [Internet]. Message to: Barbara Braun. 2012 Jul 16

[cited Jul 16]. [3 paragraphs].

11 Merriam-Webster [Internet]. Merriam-Webster, Inc.; c2012 [cited

2012 Jan 31]. Definition of SYNERGY; [about 2 screens].

Available from: http://www.merriam-webster.com/dictionary

/synergy.

145

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

12 Occupational Safety and Health Administration [Internet]. [cited

2012 J

an 31]. OSHA’s Cooperative Programs; [about 1 screen].

Available from: http://www.osha.gov/dcsp/compliance_assistance

/index_programs.html.

13 Halbesleben JR, Wakefield DS, Wakefield BJ. Work-arounds in

health care settings: Literature review and research agenda Health

Care Manage Rev. 2008 Jan-Mar;33(1):2–12.

14 Task Force on the Prevention of Workplace Bullying [Internet].

c2001 [cited 2012 Jan 31]. Report of the Task Force on the

Prevention of Workplace Bullying: Dignity at Work—The

Challenge of Workplace Bullying; [about 90 p.]. Available from:

http://www.djei.ie/publications/employment/2005/bullyingtask

force.pdf.

15 Department of Health and Human Services, Centers for Disease

Control and Prevention, National Institute for Occupational

Safety and Health [Internet]. Cincinnati (OH): Department of

Health and Human Services; c2002 [updated 2002 Apr; cited

2012 Jan 31]. Violence: Occupational Hazards in Hospitals,

DHHS (NIOSH) Publication No. 2002-101; [about 15 p.].

Available from: http://www.cdc.gov/niosh/docs/2002-101/.

146

Description of

Selected OSHA Standards

Relevant to Health Care

Source: Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers.

Occupational Safety and Health Administration, US Department of Labor. OSHA 3328-05R. 2009.

147

– Appendix C –

Description of Selected OSHA Standards Relevant to Health Care

OSHA Standards of Special Importance

Personal Protective Equipment

Standard-29 CFR 1910.132

The role of OSHA is “to assure safe and healthful working

conditions for working men and women.” Employers have a

responsibility to furnish employees ”a place of employment

which is free from recognized hazards that are causing or are

likely to cause death or serious physical harm.” In addition,

employers must comply with occupational safety and health

standards promulgated by OSHA or by a state with an OSHA-

approved state plan. (More information about state occupa-

tional safety and health programs can be found at

http://www.osha.gov/fso/osp/index.html.) OSHA standards

applicable to health care facilities are addressed in the stan-

dards for General Industry. In addition, the Respiratory

Protection standard, the Personal Protective Equipment stan-

dard, and the Bloodborne Pathogens standard have special

importance to pandemic preparedness and response.

When engineering controls, work practices, and administra-

tive controls are infeasible or do not provide sufficient protec-

tion, employers must provide appropriate personal protective

equipment (PPE) and ensure its proper use. PPE is worn to

minimize exposure to a variety of workplace hazards. PPE

can include protection for eyes, face, head, and extremities.

Gowns, face shields, gloves, and respirators are examples of

commonly used PPE within healthcare facilities.

Employers must conduct a workplace hazard assessment to

determine if hazards are present that necessitate the use of

PPE. The employer must verify that the required workplace

hazard assessment has been performed through a written

certification that identifies the workplace evaluated; the per-

son certifying that the evaluation has been performed; the

date(s) of the hazard assessment; and, which identifies the

document as a certification of hazard assessment. Based on

the hazard assessment, employers are to select PPE that will

protect employees from the identified hazards. Employees are

to receive training to ensure that they understand the hazards

present, the necessity of the PPE, and its limitations. In addi-

tion, they must learn how to properly put on, take off, adjust,

and wear PPE. Finally, employees must understand the

proper care, maintenance, and disposal of PPE.

Healthcare employers can receive more information about the

Personal Protective Equipment standard at

http://www.osha.gov/SLTC/personalprotectiveequipment

/index.html.

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

148

Description of Selected OSHA Standards Relevant to Health Care

Respiratory Protection Standard-29 CFR 1910.134 Bloodborne Pathogens Standard-29 CFR 1910.1030

The primary objective of OSHA’s Respiratory Protection stan-

dard is to protect employees against inhalation of harmful air-

borne substances or oxygen-deficient air. This standard

applies to all occupational airborne exposures where employ-

ees are exposed to a hazardous level of an airborne contami-

nant. The inhalation of pathogenic organisms known to cause

human disease is covered by this standard.

Employers are required to use feasible engineering controls

as the primary means of controlling air contaminants.

Respirators should be used for protection only when engi-

neering controls have been shown to be technologically or

economically infeasible or while they are being instituted for

the control of the hazard.

Healthcare facilities requiring the use of respirators must

implement a comprehensive respiratory protection program.

These programs are to be overseen by a qualified program

administrator and have key elements that include respirator

selection, training, medical certification, fit testing, mainte-

nance and cleaning, and program review.

Information describing all of the elements of a comprehensive

respiratory protection program and the use of respirators can

be found at http://www/osha.gov/SLTC/respiratoryprotection

/index.html.

OSHA’s Bloodborne Pathogens standard is a regulation that

protects employees against health hazards related to the

occupational exposure to bloodborne pathogens. The stan-

dard applies to any employee who is occupationally exposed

to human blood or certain other potentially infectious materi-

als (e.g., pleural fluid, any body fluids visibly contaminated

with blood, any unfixed human tissue or organ). The

Bloodborne Pathogens standard has provisions requiring

exposure control plans, engineering and work practice con-

trols, PPE, hepatitis B vaccination, hazard communication,

training, and recordkeeping.

Additional information on the Bloodborne Pathogens standard

is available at http://www.osha.gov/SLTC/bloodborne

pathogens/index.html.

General Duty Clause References

In addition to compliance with the hazard-specific safety and

health standards, employers must provide their employees

with a workplace free from recognized hazards likely to cause

death or serious physical harm. Employers can be cited for

violating the General Duty Clause of the OSH Act if they do

not take reasonable steps to abate or address such recog-

nized hazards.

OSHA. Occupational Safety and Health Act of 1970 (OSH

Act).

29 U.S.C. 654(a)(1).

Index

Accidents/incidents. See also Incident reporting and sur-

veillance systems

investigation of, 29, 32–33

patient safety programs, management systems, and

investigation of, 32–33

safety and health management system component, 29

Accreditation Council for Graduate Medical Education

(ACGME) Duty Hour Standards, 112, 116

ACR (American College of Radiology), 94, 96

Action plan, 53–54

Administrative and organizational controls

effectiveness of and cost of, 35

hazardous drug safe handling interventions, 91

hierarchy of controls, 34, 35

infection prevention and control, 83

safe patient handling and, 65

sharps injury prevention, 79

Adverse events

active errors, 36, 37

Adverse Events Prevented Calculator (IHI), 22

contributing factors, 36, 37

disclosure barriers and reasons to disclose, 120

disclosure of to patients, 119

emotional response of patients to, 118

emotional response of worker to, 117–124

fatigue, workload demands, and staffing levels, 112

HROs and, 7

human factors engineering and, 36

impact and costs of, 118

interventions to prevent or reduce, 14

latent conditions and, 36, 37

reporting of, vii, 117

reporting of, blame-free, 32, 52, 132

response to, vii

support for patient following, 119

support system for staff following, 33, 117–124

Agency for Healthcare Research and Quality (AHRQ)

built environment and patient safety, recommenda-

tions on, 40

Denver Health toolkit and case example for design of

health care system, 38

“The Effect of Health Care Working Conditions on

the Quality of Care,” 11

“Health Care Comes Home,” 40, 43

Hospital Survey on Patient Safety Culture, 19

human factors and safe design resources, 41

infection transmission prevention resources, 86

Medical Office Survey on Patient Safety Culture, 19

Nursing Home Survey on Patient Safety Culture, 19

patient outcomes and staffing levels, 112

Patient Safety and Quality, 36

Quality Indicator Toolkit for Hospitals, 86

RCA recommendations, 53

research and recommendations role of, 133

return on investment resources, 22

TeamSTEPPS, 57, 58

AHRQ. See Agency for Healthcare Research and Quality

(AHRQ)

AIHA (American Industrial Hygiene Association), 41

Airborne contaminants, 148

Alliance for Radiation Safety in Pediatric Imaging, 96

American Association of Critical-Care Nurses, 102

American College of Radiology (ACR), 94, 96

American Industrial Hygiene Association (AIHA), 41

American Nurses Association (ANA)

National Database of Nursing Quality Indicators

(NDNQI), 47

safe patient handling resources, 66

sharps injuries resources, 81

violence and assault resources, 102

work schedules review and recommendations,

112–113, 116

American Society of Health Systems Pharmacists

(ASHP), 92

Anesthesia, death rate associated with, 8

Anesthetic gases, 84, 89, 136

Antineoplastic drugs, 84, 88–89, 90–91, 92–94

APIC (Association for Professionals in Infection Control

and Epidemiology), 86

ASHP (American Society of Health Systems

Pharmacists), 92

Assaults. See Violence and assaults

Assistive devices

149

– ● –

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

MSD and fall prevention, 38

MSD and safe patient handling, 38, 62, 63, 65, 73

training for use of, 38

Association for Professionals in Infection Control and

Epidemiology (APIC), 86

Association of Occupation Health Professionals (AOHP)

infections, member concerns about, 82

safe patient handling resources, 67

Association of periOperative Registered Nurses (AORN), 57

Atlantic Health System “Red Cell” program case study,

107–108

Aviation-based human factors, 36

Bariatric patient safety case study, 68–70

Behavioral controls

hazardous drug safe handling interventions, 91

safe patient handling and, 65

sharps injury prevention, 80

Behavioral health services

Lemuel Shattuck Hospital program to reduce assaults in

behavioral health unit case study, 104–106

violence and assault risks, 95

Behaviors and relationships

Behavioral Threat Management Program case study,

108–111

bullying, harassment, and horizontal violence, 97–99

Civility, Respect, and Engagement in the Workplace

(CREW) case study, 27, 29, 34

civility in the workplace, 27

disruptive behavior, 95, 97–99, 101–102

safety culture, behaviors that undermine, 33, 97–99, 104

safety culture and, 10, 12

Sentinel Event Alert on behaviors that undermine culture of

safety, 104

Blame-free reporting system, 32, 52, 132

Bleach, 84

Bloodborne pathogens

AOHP survey on, 82

exposure prevention initiative, 79, 80

OSHA standard and requirements, 136, 148

sharps injuries and exposure risks, 78–79, 80

Bullying, harassment, and horizontal violence, 97–99

Burnout, 27, 51, 111–112, 118

Business case for safety, vii–viii, 11–12, 132. See also Return on

investment (ROI)

Canadian Centre for Occupational Health & Safety, Joint

Occupational Health & Safety Committee, 86

Canadian Patient Safety Institute, 52, 57

Case studies

Atlantic Health System “Red Cell” program, 107–108

Duke HomeCare & Hospice Director Safety Rounds,

48–50

effectiveness of in presenting story and facts, vii

Intermountain Health safe patient handling program, 71–72

Kaiser Permanente slip, trip, and fall prevention, 76–77

Lancaster General Hospital bariatric patient safety, 68–70

Lemuel Shattuck Hospital program to reduce assaults in

behavioral health unit, 104–106

St. Vincent’s Medical Center transformation to high reliabil-

ity culture, 15–19

University of Missouri Health Care forYOU second victim

support program, 119–124

Veterans Health Administration (VHA) Behavioral Threat

Management Program, 108–111

Veterans Health Administration Civility, Respect, and

Engagement in the Workplace (CREW), 27, 29, 34

Catheter-associated urinary tract infections (CAUTI), 47, 82

CEA (Cost-Effectiveness Analysis), 22

Center for Devices and Radiological Health, 94

Center for Health Care Strategies, 22

Center for Health Design (CHD), 40, 42

Center for Maximum Potential Building Systems, 40

Centers for Disease Control and Prevention (CDC)

Cost-Effectiveness Analysis (CEA), 22

Guideline for Isolation Precautions, 82

hand hygiene guidelines, compliance with, 31, 32

Healthy People 2020, 83

human factors and safe design resources, 41–42

infection transmission prevention resources, 86

influenza prevention and control recommendations, 31, 83

National Healthcare Safety Network (NHSN), 46–47

National Healthy Worksite Program, 58

National Surveillance System for Healthcare Workers

(NaSH), 46–47

One & One Campaign, 80

radiation exposure risks, 89

return on investment resources, 22

sharps injury rates and prevalence, 78

standard precautions information, 32, 83–84

Central line–associated blood stream infections (CLABSI), 47,

Central line– insertion supply kits and carts, 38

Champions, 51, 133

Change management methodologies and tools, 40

CHD (Center for Health Design), 40, 42

Chemical agents, 25, 84

Chemotherapy drugs, 84, 88

Civility, Respect, and Engagement in the Workplace (CREW)

case study, 27, 29, 34

CLABSI (central line–associated blood stream infections), 47,

Cleaning chemicals, 38, 84

Close calls, vii

Clostridium difficile, 47, 84

Coaches, frontline safety, 51, 133

Code of Federal Regulations, 112

150

Index

Communication

closed loop communication strategies, 52

CUS (Concerned, Uncomfortable, and Safety Issue), 52, 58

Hand-off Communication Targeted Solution Tool, 52

high reliability organizations and, 51

huddles, daily and unit-based, 11–12, 16, 17, 51–52, 132

patient and worker safety, integration of, 132–133

quality and safety of care, open discussion about, 33

repeat back, 52

resources, 57

safety and communication failure, 51

safety culture and, 10, 12

SBAR communication, 52

SHARE communication tool, 52

teach back, 52

tools to enhance, 51–52

Concentrated electrolytes, 38

Concerned, Uncomfortable, and Safety Issue (CUS), 52, 58

Cost-Effectiveness Analysis (CEA), 22

CREW (Civility, Respect, and Engagement in the Workplace)

case study, 27, 29, 34

Crew Resource Management, 36

Criminal acts, 99–100

Crossing the Quality Chasm (IOM), 8

CSS (Culture of Safety Survey), 21

Culture of Safety Survey (CSS), 21

CUS (Concerned, Uncomfortable, and Safety Issue), 52, 58

DART (Days Away, Restrictions and Transfers), 17, 44, 45

Data collection and analysis. See also Performance measurement

environment, monitoring of, 137

financial data related to improvement interventions, 44

on HAIs, 46

interrelated patient and worker safety data reporting, 44,

132

on multidrug-resistance organisms, 46

OSHA topics matched to Joint Commission standards, 136,

137

outcome data sources, 44–45

patient safety incidents, 45–46, 53

safety performance data collection and analysis, 132

Days Away, Restrictions and Transfers (DART), 17, 44, 45

Decubitus ulcers, 11

Define, measure, analyze, improve, and control (DMAIC), 40

Denver Health toolkit and case example for design of health

care system, 38

Dialysis Surveillance Network (DSN), 46

Disruptive behavior, 95, 97–99, 101–102

DMAIC (define, measure, analyze, improve, and control), 40

“Draft Guidelines for Adverse Event Reporting and Learning

Systems” (WHO), 45

DSN (Dialysis Surveillance Network), 46

Duke University Health System, Duke HomeCare & Hospice

Director Safety Rounds case study, 48–50

medication reconciliation policy, 49

Duty Hour Standards (ACGME), 112, 116

Ecologically sound design, construction, and operations tech-

niques, 40

ECRI Institute, 103

Education and training

assistive devices, training for use of, 38

champions, coaches and unit peer leaders for provision of,

51, 133

MSD signs and symptoms, education on, 38

occupational illnesses and injuries, training to prevent, 38

ongoing education and training, participation in, 32

organizational culture and opportunities for, 51

OSHA topics matched to Joint Commission standards, 137

patient handling procedures and equipment, 62, 65

patient safety improvement initiative, 132

patient safety programs, management systems, and, 32

quality and safety, focus of education on, 32

safety and health management system component, 27, 28

teamwork training, 31, 32

Electrical safety, 137

Elimination, 34, 35, 38

Emotional injuries and illness (second victims)

impact of, 117–118

interventions to support emotional needs, 118–119

Kimberly Hiatt suicide, 118, 119

reciprocal cycle of error and, 118

resources, 123

second victim, use of term, 117, 118

understanding of, 117

University of Missouri Health Care forYOU second victim

support program case study, 119–124

Engineering controls

hazardous drug safe handling interventions, 91

hazards, prevention and control of, 28, 65

hierarchy of controls, 34, 35

infection prevention and control, 83

safe patient handling and, 65

Environment of Care (EC) standards

environment of care risks, staff role in reporting, 31, 32

OSHA topics matched to, 135, 136, 137

safety and security risks, identification and elimination of,

Environment of care and facility

adverse event contributing factors, 37

data collection and analysis to monitor environment, 137

design of for safety resources, 41–44

ecologically sound design, construction, and operations

techniques, 40

ergonomics and worker capability strategies, role in, 36, 38

hazardous drug safe handling interventions, 91

151

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

monitoring conditions in, 31

musculoskeletal injury risks and prevention interventions,

OSHA topics matched to Joint Commission standards, 136

“Prevention through Design” initiative (NIOSH), 39, 41

resources, 57–60

risks and hazards, 14, 32

safer design of built environment, 38–40

safety improvement interventions, 15

security and violence prevention, 100–101, 107–108

Environment of Care Tracer Workbook, 53

Equipment

of assistive devices, 38

assistive devices, 38, 62, 63, 65, 73

ergonomics and worker capability strategies, role in, 36, 38

hazardous drug safe handling interventions, 91

musculoskeletal injury risks, 63

OSHA topics matched to Joint Commission standards, 137

Errors. See also Incident reporting and surveillance systems

blame-free reporting, 32, 52, 132

causes of, 8

deaths from, 1

disclosure of to patients, 119

emotional response of patients to, 118

emotional response of worker to, 117–124

fatigue, workload demands, and staffing levels, 112

impact and costs of, 118

organizational culture and prevention of, 10

patient hazards, 25

reduction of, analysis of information for, 33

reduction of, model for, 8–9

reporting of, 117

support for caregiver following, 33, 117–124

support for patient following, 119

underreporting of, 45

European Agency for Safety and Health at Work, 58

European Union, 58, 112

European Working Time Directive, 112

Evidence-based practices, 2

Evidence-based Synthesis Program (ESP) Center, 58

Expertise, deference to, 9

Facilities Guidelines Institute

built environment and patient safety, recommendations on,

Guidelines for Design and Construction of Health Care

Facilities, 43

Failure

calculation of failure rate, 8

identification and mitigation of, 9

preoccupation with, 7, 8, 9, 11, 117

prevention of, 8

process design and, 9

Failure Mode and Effects Analysis (FMEA), 53

Falls, patient

assistive devices to prevent, 38

incidence rates and prevalence of, 74

nursing hours per day and number of, 11

prevention of, 13, 40

risks and hazards, 74

Fatigue, workload demands, and staffing levels, 111–117

impact of, 111–112

patient safety and, 112

regulation and strategies to combat fatigue, 112–115

resources, 116–117

shift length and scheduling, 111, 112

worker well-being and patient safety interventions, 113–115

work schedules review and recommendations, 112–113, 114

Fault tree analysis, 53

FDA (Food and Drug Administration), 94

Federal requirements. See Local, state, and federal requirements

Feedback loop for safety incidents, 45, 46, 53

Financial data related to improvement interventions, 44

Fire safety, 137

Flooring surfaces, 74, 75, 76–77, 137

FMEA (Failure Mode and Effects Analysis), 53

Food and Drug Administration (FDA), 94

Frontline safety coaches, 51

Gases and vapors

OSHA topics matched to Joint Commission standards, 136,

137

risks and hazards, 84, 89, 136

GE Health Care, 123

General Duty Clause (OSHA), 148

Glossary, 139–145

Green Guide for Health Care (Center for Maximum Potential

Building Systems and Health Care Without Harm), 40

Guideline for Isolation Precautions (CDC), 82

Guidelines for Design and Construction of Health Care

Facilities (Facilities Guidelines Institute), 43

Hand hygiene

guidelines on

adherence to, 38

compliance with, 31, 32

infection prevention and control and, 38, 82, 84

resources, 84

standard precautions, 84, 85

Hand-off Communication Targeted Solution Tool, 52

Harassment and bullying, 97–99

Hazardous drugs and substances. See also Radiation

disposal of, 89

exposure to

impact of, 88

152

Index

methods of, 84

survey on, 89

NIOSH definition, 84

NIOSH recommendations, 84, 89, 90

OSHA guidelines for management of, 84, 88, 93

OSHA topics matched to Joint Commission standards, 136

policy requirements, 84, 88–89

resources, 84, 92–94

risks and hazards, 84, 88

safe handling interventions, 14, 88–89, 91

Hazardous materials and waste

disposal of, 89

inventory of, maintenance of a written, 31

OSHA topics matched to Joint Commission standards,

136–137

risks and hazards, 25

HBV (hepatitis B virus), 78, 79, 80

HCV (hepatitis C virus), 78, 79, 80

HCWH (Health Care Without Harm), 40, 42

Health and Research and Educational Trust, 58

Health and Safety Practices Survey of Healthcare Workers

(NIOSH), 89

Health care

barriers to high levels of safety in, 8

high-hazard, high-risk activities, 25

high reliability and, 8–9

Healthcare and Social Assistance Sector Council (NORA), 2,

96, 133

Health care–associated infections (HAIs)

data collection and analysis on, 46

impact of, 83

incidence rates and prevalence of, 82

prevention of, 82, 83–84

resources, 86–88

risks and hazards for, 25, 82

tracking of, examples of systems for, 46–47

Health Care at the Crossroads white paper (Joint

Commission), 60

“Health Care Comes Home” (National Academies of Sciences

and Agency for Healthcare Research and Quality), 40, 43

Healthcare Personnel Safety Component (NHSN), 46–47

Health Care Without Harm (HCWH), 40, 42

Healthier Hospitals Initiative, 40

Healthy People 2020 (CDC), 83

Hepatitis B virus (HBV), 78, 79, 80

Hepatitis C virus (HCV), 78, 79, 80

Hiatt, Kimberly, 118, 119

High-hazard, high-risk activities, 25, 31

High reliability

achievement of, changes in organization for, 9–10

barriers to in health care, 8

health care and, 8–9

mindfulness and, 7–8, 9

organizational culture to support, 10

safety culture and, 131

High reliability organizations (HROs)

communications and, 51

concept and definition of, 7–8

cultural characteristics and principles, 7–8, 9, 117

cultural characteristics and principles, adoption of, 48, 57

safety, preoccupation with, 11

safety functions, coordination of across departments, 26, 61

St. Vincent’s Medical Center transformation to high reliabil-

ity culture case study, 15–19

High risk patients, 11

HIV (human immunodeficiency virus), 78, 79, 80

Home health care

Duke HomeCare & Hospice Director Safety Rounds case

study, 48–50

Fast Fact Sheets and NIOSH resources, 59–60

“Health Care Comes Home” (National Academies of

Sciences and Agency for Healthcare Research and Quality),

40, 43

human factors and patient safety concerns and recommen-

dations, 40

violence and assault prevention, 101

violence and assault risks, 97, 98

Horizontal violence, 97–99

Hospitals, violence in, 95, 97

Hospital Survey on Patient Safety Culture (AHRQ), 19

Hospital Transfusion Service Safety Culture Survey (HTSSCS),

Housekeeping

hazardous drug handling, 90

sharps injuries, 78

slip, trip, and fall (STF) injury prevention, 75

HTSSCS (Hospital Transfusion Service Safety Culture Survey),

Huddles, daily and unit-based, 11–12, 16, 17, 51–52, 132

Human factors engineering and ergonomics

adverse events and, 36

applications outside health care, 36

concept and definition of, 36

growth of interest in, 38

importance of, 38

MSD prevention or alleviation, 36, 65

patient handling, transfer, and lifting and, 65

quality and safety of care and, 36

resources, 41–44

safety improvement interventions, 14, 35–36

systems perspective for, 36

Human immunodeficiency virus (HIV), 78, 79, 80

Human Resources (HR) standards

ongoing education and training, participation in, 32

OSHA topics matched to, 135, 137

Ice and snow removal, 75

Image Gently program (Society of Pediatric Radiology), 91, 94,

153

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Image Wisely (ACR and RSNA), 94, 96

Incident reporting and surveillance systems

barriers to effective use of, 45

blame-free reporting, 132

blame-free reporting system, 32, 52

development of, 45, 52–53, 132

effective systems, 45

examples of, 46–47

feedback loop for safety incidents, 45, 46, 53

increase in reporting events, 45–46

patient-assisted incident reporting, 118–119

patient safety applications, 45

real-time reporting strategies, 53

underreporting challenges, 45

Individual tracers, 53

Infection prevention and control. See also Health care–associ-

ated infections (HAIs)

guidelines for, compliance with, 82

hand hygiene and, 38, 82, 84

interventions and initiatives, 13

examples of, 83–84

implementation of, 31–32

resources, 86–88

safety culture and, 83

standard precautions, 32, 38, 83–84, 85

workplace conditions, job demands, and worker capabilities,

Infection Prevention and Control (IC) standards

infection prevention and control activities, implementation

of, 31–32

infectious diseases, prevention of transmission of, 32

influenza vaccinations, 32, 83

OSHA topics matched to, 136

standard precautions use, 32

Infectious agents and diseases

epidemics, 80, 82

impact of, 83

incidence rates and prevalence of transmission, 82

prevention of transmission of, 32, 80, 82–84

resources, 86–88

risks and hazards, 25, 82

sharps injuries and exposure risks, 78–79

Influenza

outbreaks of, 82

prevention and control of

CDC recommendations, 31, 83

vaccinations for workers, 31, 32, 83

transmission of, 83

Information Management (IM) standards, 136

Injury and Illness Report (OSHA Form 301), 45

Institute for Healthcare Improvement (IHI)

Adverse Events Prevented Calculator, 22

current processes, tool for mapping, 38

emotional injuries and illness (second victims) resources,

123

error reduction, model for, 8–9

FMEA (Failure Mode and Effects Analysis), 53

human factors and safe design resources, 43

infection transmission prevention resources, 86

Leadership Guide to Patient Safety, 48, 59

leadership resources, 59

reliability, definition of, 8

return on investment resources, 22

SBAR toolkit, 52

Institute for Safe Medication Practices, Medication Safety Self

Assessment (MSSA), 21

Institute of Medicine (IOM)

Committee on Optimizing Graduate Medical Trainee

(Resident) Hours and Work Schedules, 112

Crossing the Quality Chasm, 8

To Err Is Human, 1, 26, 45

work schedules review and recommendations, 112, 113

Intermountain Health safe patient handling program case

study, 71–72

International Agency for Research on Cancer (WHO), 89

International Association for Healthcare Security and Safety,

103

International Council of Nurses (ICN), 104

International Critical Incident Stress Foundation

emotional injuries and illness (second victims) resources,

123

violence and assault resources, 103

Interpretations, reluctance to simplify, 7, 8, 9

Joint Commission

emotional injuries and illness (second victims) resources,

123

hazardous drug and safe handling policy requirements, 84

Health Care at the Crossroads white paper, 60

human factors and safe design resources, 44

infection transmission prevention resources, 87–88

Measuring Hand Hygiene Adherence, 84, 87

Robust Process Improvement (RPI), 40

Sentinel Event Alert

behaviors that undermine culture of safety, 104

radiation risks, 94–95, 96

violence prevention, 100, 104

violence and assault resources, 104

Joint Commission Center for Transforming Healthcare

Hand-off Communication Targeted Solution Tool, 52

SHARE communication tool, 52

Joint Commission Resources, 43

Joint Commission standards

compliance with, guidance on, 2

influenza vaccinations, 83

OSHA topics matched to, 135–137

patient safety programs, management systems, and, 27, 30–33

Joint Occupational Health & Safety Committee, Canadian

Centre for Occupational Health & Safety, 86

154

Index

Kaiser Permanente slip, trip, and fall prevention case study, 76–77

Labor Statistics, Bureau of (U.S. Department of Labor)

hospital violence data, 95

musculoskeletal injuries, 62

occupational illnesses and injuries data, 26

Lancaster General Hospital bariatric patient safety case study,

68–70

Lateral violence, 98

Leadership (LD) standards

behaviors that undermine safety culture, management of, 33

blame-free reporting system, 32

culture of safety, 33

error reduction, analysis of information for, 33

OSHA topics matched to, 135

patient safety program, 30

proactive risk assessment, 32, 33

quality and safety, focus of education on, 32

quality and safety of care, open discussion about, 33

quality and safety of care, reports on, 30

quality and safety of care initiatives, 31

root cause analysis requirement, 32, 53–54

staffing for safe and quality care, 30

Leadership and management

adverse event contributing factors, 37

Duke HomeCare & Hospice Director Safety Rounds case

study, 48–50

hazardous drug safe handling interventions, 91

patient and worker safety, integration of, 133

patient outcomes and, 11, 12

patient safety programs, management systems, and, 30

quality and safety of care, role in, 25, 30, 48

resources, 57–60

safety and health management system component, 27, 28

safety culture and, 10, 12

safety improvement strategies and tools, 47–51

staff engagement in improving safety and, 50–51

structures and systems for patient safety, 30

WalkRounds, 48–50

worker outcomes and, 11, 12

worker well-being and patient safety interventions, 113–115

workplace conditions and job demands, role in fitting to

worker capabilities, 36, 38

Leadership Guide to Patient Safety (IHI), 48, 59

Lean, 40

Lemuel Shattuck Hospital program to reduce assaults in behav-

ioral health unit case study, 104–106

Life Safety (LS) standards, 137

Lifting and transfer. See Patient handling, transfer, and lifting

List of Antineoplastic and Other Hazardous Drugs in Healthcare

Settings (NIOSH), 84, 93

Local, state, and federal requirements, 2

Log of Work-Related Injuries and Illnesses (OSHA Form 300),

44, 137

Management. See Leadership and management

Massachusetts Department of Health and Human Services,

sharps injuries resources, 81

MDROs (multidrug-resistance organisms), 46, 47, 82

Measles, 82

Measuring Hand Hygiene Adherence (Joint Commission), 84, 87

Medical errors. See Errors

Medically Induced Trauma Support Services (MITSS), 123

Medical Office Survey on Patient Safety Culture (AHRQ), 19

Medication errors

fatigue, workload demands, and staffing levels, 112

risks and hazards, 25

Medication Management (MM) standards, 136

Medication reconciliation policy, 49

Medication Safety Self Assessment (MSSA), Institute for Safe

Medication Practices, 21

MedWatch program (FDA), 94

Methicillin-resistant Staphylococcus aureus (MRSA), 82

Mindfulness and high reliability, 7–8, 9

MITSS (Medically Induced Trauma Support Services), 123

Mock tracer activities, 53

Modified Organizational Climate Description Questionnaire

(OCDQ), 20

Modified Stanford Instrument (MSI) Patient Safety Culture

Survey, 20

MRSA (methicillin-resistant Staphylococcus aureus), 82

MSSA (Medication Safety Self Assessment), Institute for Safe

Medication Practices, 21

Multidrug-resistance organisms (MDROs), 46, 47, 82

Musculoskeletal disorders (MSDs)

assistive device use to prevent, 38, 62, 65, 73

costs of, 62

education and training to prevent, 62, 65

ergonomics and prevention or alleviation of, 36, 38, 65

impact of, 62, 65

incidence rates and prevalence of, 26, 62

prevention resources, 42, 66–68

risks for, 36

safe patient handling and

case studies, 68–72

interventions to reduce injuries, 65

resources, 66–68

risks for injuries, 62–65

signs and symptoms, education on, 38

NaSH (National Surveillance System for Healthcare Workers),

46–47

National Academies of Sciences, 40, 43

National Center for Organization Development (NCOD), 34

National Database of Nursing Quality Indicators (NDNQI),

National Healthcare Safety Network (NHSN), 46–47

Healthcare Personnel Safety Component, 46–47

Patient Safety Component, 47

155

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

National Healthy Worksite Program (CDC), 58

National Institute for Occupation Safety and Health (NIOSH)

hazardous drug and safe handling policy requirements, 84,

89, 90

hazardous drugs and substances resources, 92–93

hazardous substances, information on, 84

hazard prevention and control recommendations, 35

Health and Safety Practices Survey of Healthcare Workers,

human factors and safe design resources, 41–42

leadership resources, 59–60

List of Antineoplastic and Other Hazardous Drugs in

Healthcare Settings, 84, 93

musculoskeletal injury risks, 62, 63–64

NORA program, 131, 133 (see also National Occupational

Research Agenda (NORA))

Occupational Health and Safety Network (OHSN), 47

“Prevention through Design” initiative, 39, 41

radiation resources, 96

research and recommendations role of, 133

return on investment resources, 22–23

Roundtable Project and Meeting support, 2

safe patient handling resources, 67

Sector Council, 133

sharps injuries resources, 81

slip, trip, and fall (STF) prevention, 76

State of the Sector document, 84

surveillance systems, 47

violence and assault resources, 103–104

workplace environment resources, 59–60

workplace violence, definition of, 95

Work-Related Injury Statistics Query System (Work-

RISQS), 47

National Institutes of Health (NIH), National Institute of

Environmental Health Sciences, 89

National Nosocomial Infection Surveillance System (NNIS),

National Occupational Research Agenda (NORA)

creation of, 133

Healthcare and Social Assistance Sector Council, 2, 96, 133

occupational illnesses and injuries report, 25–26

occupational safety and health research and, 133

Roundtable Project and Meeting support, 2

worker well-being and patient safety interventions, 113

National Patient Safety Goals, 32

National Quality Forum (NQF)

infection transmission prevention resources, 87

Safe Practices for Better Healthcare, 27, 30–33

National Reporting and Learning Systems, 45–46

National Research Council

Board on Human-Systems Integration, 36

human factors and safe design resources, 43

National Safety Council (NSC), 76

National Surveillance System for Healthcare Workers (NaSH),

46–47

National Transportation and Safety Board, 112

NCOD (National Center for Organization Development), 34

NDNQI (National Database of Nursing Quality Indicators),

Near-miss events

emotional response of worker to, 117–124

interventions to prevent or reduce, 14

reporting of, vii, 14

reporting of, blame-free, 52, 132

response to, vii

Needlestick Safety and Prevention Act, 78

NHSN (National Healthcare Safety Network), 46–47

NIOSH. See National Institute for Occupation Safety and

Health (NIOSH)

Nitrogen mustard, 84

NORA. See National Occupational Research Agenda (NORA)

NQF. See National Quality Forum (NQF)

Nursing Home Survey on Patient Safety Culture (AHRQ), 19

Occupational Health and Safety Network (OHSN), 47

Occupational illnesses and injuries. See also Emotional injuries

and illness (second victims)

DART, 17, 44, 45

data on, 1

hazards for workers and, 25, 27

incidence rates and prevalence of, 25–26

Injury and Illness Report (OSHA Form 301), 45

injury and illness tracking systems, 45–47

Log of Work-Related Injuries and Illnesses (OSHA Form

300), 44, 137

National Healthy Worksite Program (CDC), 58

NORA report on, 25–26

organizational culture and, 10

training for prevention of, 38

Occupational Safety and Health Administration (OSHA), 148

Bloodborne Pathogens standard, 136, 148

compliance with regulations, guidance on, 2

Days Away, Restrictions and Transfers (DART), 17, 44, 45

ergonomics and quality of care, 36

fault tree analysis, 53

General Duty Clause, 148

hazardous drug and safe handling policy requirements, 84

hazardous drugs and substances resources, 93

hazardous drugs management guidelines, 84, 88, 93

infection transmission prevention resources, 87

Injury and Illness Report (Form 301), 45

Joint Commission standards, OSHA topics matched to,

135–137

Log of Work-Related Injuries and Illnesses (Form 300), 44,

137

occupational illnesses and injuries report, 26

PPE standard, 28, 147

Respiratory Protection standard, 148

return on investment resources, 23–24

156

Index

role of, 147

safe patient handling resources, 68

Safety and Health Add Value., 23

safety and health management system guidelines, 26, 28–29

$afety Pays” program, 23

slip, trip, and fall (STF) prevention, 76

standards, compliance with, 147

Summary (Form 300A), 45

Voluntary Protection Program (VPP), 15, 68–70, 135

workplace violence prevention program, 99, 104

Occupational safety and health research and, 131, 133, 134

OCDQ (Modified Organizational Climate Description

Questionnaire), 20

OHSN (Occupational Health and Safety Network), 47

Oncology Nurses Society (ONS), 93–94

One & One Campaign (CDC), 80

ONS (Oncology Nurses Society), 93–94

Operations, sensitivity to, 7, 8, 9

Organizational climate

concept and definition of, 10

structural and process factors that affect worker and patient

outcomes, 11, 12

Organizational Climate Questionnaire, 20

Organizational controls. See Administrative and organizational

controls

Organizational culture. See also Safety culture

adverse event contributing factors, 37

concept and definition of, 10

education and training opportunities and, 51

error prevention and, 10

high reliability, support for, 10

high reliability and mindfulness, 7–8, 9

patient outcomes and, 10, 11, 12

staff engagement in improving safety and, 50–51, 132–133

staff outcomes and, 10, 11, 12

staff perception of values and safety climate, 51

Organization of work, 25

Patient handling, transfer, and lifting

assistive devices for, 38, 62, 63, 65, 73

case studies

Intermountain Health safe patient handling program,

71–72

Lancaster General Hospital bariatric patient safety, 68–70

education and training for, 62, 65

flowchart algorithm for safe transfer, 38, 39

injuries to patients during, 62, 65

OSHA topics matched to Joint Commission standards, 136

repositioning and lifting scoring tool, 73

resources, 66–68

risks and hazards, 25, 62–65

safe handling and MSDs, 62–72

safety improvement interventions and initiatives

administrative and organizational controls, 65

behavioral controls, 65

benefits safe patient lifting program, 66

engineering controls, 65

examples of, 13, 65

potential barriers to, 65, 72

strategies to fit worker capabilities, 38

Patient outcomes

fatigue, workload demands, and staffing levels, 112

handling and lifting injuries, 62, 65

leadership role in, 11, 12

organizational culture and, 10

safety culture and, 11

structural and process factors that affect, 11, 12

workers role in, 11, 12

Patients

emotional response of errors and adverse events, 118

high-hazard, high-risk activities, 25

satisfaction of, 10, 11, 12, 51

support for following error or adverse event, 119

Patient safety. See also Incident reporting and surveillance sys-

tems

coordination of worker and patient safety functions, 26,

30–33, 61

definition of and use of term, 2

dimensions across safety culture tools, 10

fatigue, workload demands, and staffing levels, 111–117

growth of interest in, 26

hierarchy of controls and interventions to resolve risks,

34–35, 36, 38

HROs and preoccupation with, 11

leadership role in, 30

performance improvement and coordination of patient and

worker safety issues, 40, 44

responsibility for, 26

ROI and, vii–viii, 11–12

siloed safety programs, vii

synergy and interrelationship between worker safety and, vii,

1, 11, 131–134

threats to, causes of, 8

workers role in, 11

workplace conditions and quality of work life and, 58

Patient Safety and Quality (AHRQ), 36

Patient Safety and Quality Improvement Act (Patient Safety

Act, 2005), 45

Patient Safety Component (NHSN), 47

Patient Safety Culture in Healthcare Organizations Survey

(PSCHO), 20

Patient Safety Culture Questionnaire, Veterans Administration

(VHA PSCQ), 21

Patient Safety Culture Survey, Modified Stanford Instrument

(MSI), 20

Patient Safety Organizations (PSOs), 45

PDSA (plan-do-study-act), 40

157

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

Performance improvement

activities and initiatives

evaluation of impact of, 44

financial data related to, 44

recognition and rewards for efforts, 51

staff role in design of, 40, 50–51, 132–133

topic areas for, 40, 61 (see also specific topics)

coordination of patient and worker safety issues, 40, 44, 132

OSHA topics matched to Joint Commission standards, 135

strategies and models for, 40

Performance Improvement (PI) standards, 135

Performance measurement

improvement initiatives, evaluation of impact of, 44

injury and illness tracking systems, 45–47

safety performance data collection and analysis, 132

Personal protective equipment (PPE)

effectiveness of and cost of, 35

hazardous drug and substance handling and requirement for,

89, 90, 91

hierarchy of controls, 28, 34, 35

infection prevention and control and, 83, 84

Joint Commission standards and requirements, 32

NIOSH resource, 92

OSHA standard and requirements, 28, 147

resources, 86

standard precautions, 84, 85

PES-NWI (Practice Environment Scale of the Nursing Work

Index), 21

Physical agents, 25

Plan-do-study-act (PDSA), 40

Potassium chloride, redesign of process related to use of, 38

PPE. See Personal protective equipment (PPE)

Practice Environment Scale of the Nursing Work Index

(PES-NWI), 21

Premier Healthcare Alliance, 80

“Prevention through Design” initiative (NIOSH), 39, 41

Proactive risk assessment

blame-free reporting and, 32

error reduction, analysis of results for, 33

requirement for, 31

Processes. See Systems and processes

Program-specific tracers, 53

PSCHO (Patient Safety Culture in Healthcare Organizations

Survey), 20

PSOs (Patient Safety Organizations), 45

Puget Sound Human Factors and Ergonomics Society, 44

Quality and safety of care. See also Patient safety

discussion about, open, 33

human factors engineering and ergonomics and, 36

initiatives for, participation in, 31

Joint Commission standards on, 30–33

leadership role in, 25, 30, 48

safety culture and, 25

Quality Indicator Toolkit for Hospitals (AHRQ), 86

Radiation

exposure to, 89

impact of exposure, 89, 91

interventions to reduce risks, 91, 94–95

resources, 96

risks and hazards, 84, 89

Sentinel Event Alert on radiation risks, 94–95, 96

Radioactive iodide, 89

Radiological Society of North America (RSNA), 94, 96

RCA. See Root cause analysis (RCA)

Reliability. See also High reliability; High reliability organiza-

tions (HROs)

calculation of, 8

concept and definition of, 8

improvement of, model for, 8–9

Repeat back (teach back), 52

Repetitive tasks, 25

Resilience, commitment to, 7, 8, 9

Respiratory hygiene, 85

Respiratory Protection standard (OSHA), 148

Restraint risks and hazards, 25

Return on investment (ROI)

calculation of, 12, 22–24

literature on, 12

patient and worker safety and, vii–viii, 11–12, 132

Risks and hazards

analysis of hazards, 31

assessment of hazards for PPE use, 147

engineering controls, 28, 65

hierarchy of controls and interventions to resolve, 34–35,

36, 38

identification and mitigation of, 31, 32–33, 38, 132

integrated organizationwide risk assessment, 32–33

prevention and control of

hierarchy of controls and, 34–35, 36, 38

patient safety programs, management systems, and, 31–32

safety and health management system component, 27, 28

tools for identification of, 52–54

Robert Wood Johnson Foundation, 40, 42

Robust Process Improvement (RPI), 40

Root cause analysis (RCA)

action plan and, 53–54

AHRQ recommendations, 53

focus of, 53

Joint Commission requirements, 53–54

process for, 53–54

requirement for, 32

Roundtable Project and Meeting, 2–3, 4–5, 132–133

RPI (Robust Process Improvement), 40

RSNA (Radiological Society of North America), 94, 96

Safe Injection Practices Coalition, 80

“Safer Designs for Safer Injections” meeting (Premier

Healthcare Alliance), 80

158

Index

Safety. See also Patient safety

barriers to high levels of, 8

business case for, vii–viii, 11–12, 132

communication failure and, 51

definition of and use of term, vii, 2

HROs and preoccupation with, 11

OSHA topics matched to Joint Commission standards, 136,

137

staff engagement in improving safety, 50–51, 132–133

strategies and tools for improvement of, 47–54

synergy and interrelationship between patient and worker

safety, vii, 1, 11, 131–134

Safety and Health Add Value. (OSHA), 23

Safety and Health Leadership Quiz, 21

Safety and health management systems

activities associated with and elements of, 26–27, 28–29,

30–33

components of, 26, 27

OSHA guidelines on, 26, 28–29

patient safety programs, parallels to, 30–33

Safety Attitudes Questionnaire, 20

Safety climate

concept and definition of, 10

high-risk patients, worker stress, and, 11

interventions for improvement of, 14

staff perception of organizational values and safety climate,

Safety committees, 26

Safety culture

assessment and measurement of, 10, 11, 19–21, 33

behaviors that undermine, 33, 97–99, 104

champions, coaches and unit peer leaders to reinforce, 51,

133

concept and definition of, 10

creation of, 29, 33, 131

dimensions across safety culture tools, 10

high reliability and, 131

importance of, 9–11

infection prevention and control and, 83

interventions for improvement of

challenge of, 11

cost of, 11–12

studies on, 11

topic areas for, 11, 13–15

Leadership standards on, 33

legitimacy of, vii

organization-wide culture, vii

patient outcomes and, 11

patient safety incident reporting and, 45–46

patient safety programs, management systems, and, 33

quality and safety of care and, 25

resources, 11, 19–24

safety and health management system component, 29

trust and, vii

variation in across organization, 10

$afety Pays” program (OSHA), 23

Safety programs

coordination of patient and worker safety functions, 26,

30–33, 61

patient and worker safety, integration of, 11, 132–133

siloed programs, vii

Safety Rounds Program (Duke HomeCare & Hospice), 48–50

St. Vincent’s Medical Center transformation to high reliability

culture case study, 15–19

SARS (Severe Acute Respiratory Syndrome), 82

SBAR (Situation-Background-Assessment-Recommendation)

communication, 52

Second victims. See Emotional injuries and illness (second vic-

tims)

Security

neighborhood and facility security, safety intervention for, 13

OSHA topics matched to Joint Commission standards, 136,

137

risks

elimination of, 31

identification of, 31

violence prevention programs, 100–101, 107–108

Sentinel Event Alert, 96

behaviors that undermine culture of safety, 104

radiation risks, 94–95

violence prevention, 100, 104

Sentinel events

communication failure and, 51

patient hazards, 25

root cause analysis requirement, 32, 53–54

support system for staff following, 33, 117–124

Severe Acute Respiratory Syndrome (SARS), 82

SHARE communication tool, 52

Sharps injuries

AOHP survey on, 82

disease transmission through, 78

impact of, 78–79

incidence rates and prevalence of, 78

injection practices, 80

Needlestick Safety and Prevention Act, 78

prevention of

ergonomics and worker capability strategies, role in, 38

interventions to prevent, 13, 79–80

redesign of processes, 38

resources, 81

risks and hazards, 78–79

safety-engineered devices, 78, 80

SHEA (Society for Healthcare Epidemiology of America), 87

Situation-Background-Assessment-Recommendation (SBAR)

communication, 52

Six Sigma

levels of reliability, 8

RPI and, 40

Slip, trip, and fall (STF) injuries

impact of, 74

159

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

incidence rates and prevalence of, 46, 72, 74

interventions to prevent, 13, 74–75

Kaiser Permanente slip, trip, and fall prevention case study,

76–77

patient falls, 74

resources, 76

risks and hazards, 25, 74

SLOAPS (Strategies for Leadership: An Organizational

Approach to Patient Safety), 21

Snow and ice removal, 75

Society for Healthcare Epidemiology of America (SHEA), 87

Society of Pediatric Radiology, 91, 94, 96

Staff. See Workers (staff)

Staffing

direct caregivers, 30

fatigue, workload demands, and staffing levels, 111–117

nursing workforce, 30

quality of worklife and, 10

safe and quality care, staffing for, 30

safety improvement interventions, 14

workplace conditions, job demands, and worker capabilities,

Standardization of processes, 38

Standard precautions, 32, 38, 83–84, 85

State requirements. See Local, state, and federal requirements

Storytelling, 48

Strategies for Leadership: An Organizational Approach to

Patient Safety (SLOAPS), 21

Stress. See also Emotional injuries and illness (second victims)

high-risk patients, safety climate, and worker stress, 11

risks and hazards, 25, 34

Structures, underspecification of, 7, 8

Substitution, 34, 35

Surgical settings

hands-free transfer of instruments, 38, 80

patient hazards, 25

sharps injuries, 78

System-based tracers, 53

Systems and processes

Denver Health toolkit and case example for design of health

care system, 38

design of, 9

design of for safety, 38

design of for safety resources, 41–44

error causes, 8

failures

blame-free reporting of, 32, 52, 132

error reduction, analysis of information for, 33

HROs and preoccupation with, 7, 8, 9, 11, 117

high reliability and design of, 7–8

mapping current processes, 38

patient and worker safety, integration of, 132

standardization of processes, 38

Teach back (repeat back), 52

Teams and teamwork

establishment of team approach, 33

resources, 57, 58

safety improvement interventions, 14

training and skill-building activities, 31, 32

TeamSTEPPS (AHRQ), 57, 58

Terrorist attacks, 99–100

“The Effect of Health Care Working Conditions on the

Quality of Care” (AHRQ), 11

To Err Is Human (IOM), 1, 26, 45

Tracer methodology, 53

Training for safety and health. See Education and training

Transfer and lifting. See Patient handling, transfer, and lifting

Transfusion errors, 25

T.R.U.S.T. error prevention technique, 17

Unit peer leaders, 51, 133

University of Missouri Health Care forYOU second victim sup-

port program case study, 119–124

University of Virginia Health System sharps injuries resources,

Utility systems, 136, 137

Vapors. See Gases and vapors

Ventilation

infection prevention and control and, 83

OSHA topics matched to Joint Commission standards, 136

Veterans Health Administration (VHA), Department of

Veterans Affairs

Behavioral Threat Management Program case study,

108–111

Civility, Respect, and Engagement in the Workplace

(CREW) case study, 27, 29, 34

Evidence-based Synthesis Program (ESP) Center, 58

National Center for Organization Development (NCOD),

safe patient handling resources, 67

unit peer leaders, 51

Veterans Administration Patient Safety Culture

Questionnaire (VHA PSCQ), 21

Violence and assaults

behaviors and actions that define, 95

bullying, harassment, and horizontal violence, 97–99

case studies, 102

Atlantic Health System “Red Cell” program, 107–108

Lemuel Shattuck Hospital program to reduce assaults in

behavioral health unit, 104–106

Veterans Health Administration (VHA) Behavioral

Threat Management Program, 108–111

criminal acts, 99–100

disruptive behavior, 95, 97–99, 101–102

160

Index

home care settings, violence in, 97

horizontal violence, 97–99

hospitals, violence in, 95, 97

incidence rates and prevalence of, 95, 97

interventions to prevent or reduce, 13, 95, 99–102

recognition and rewards for efforts, 51

safety and security programs, 100–101, 107–108

violence prevention programs, 99, 104–106

lateral violence, 98

media coverage of, 95

OSHA topics matched to Joint Commission standards, 136

resources, 102–104

risks and hazards, 25, 34, 95, 97–99

Sentinel Event Alert on prevention of, 100, 104

Voluntary Protection Program (VPP, OSHA), 15, 68–70, 135

Walking surfaces, 74, 75, 76–77, 137

WalkRounds, 48–50

Washington State

hazardous drugs and substances resources, 93–94

human factors and safe design resources, 44

safe patient handling resources, 68

Worker health

definition of and use of term, 2

hazards for workers and, 25, 27

Worker outcomes

organizational culture and, 10, 11, 12

safety improvement interventions, 14

satisfaction and turnover rates, 10, 11, 12, 51

structural and process factors that affect, 11, 12

Workers (staff)

bullying, harassment, and horizontal violence, 97–99

disruptive behavior, 95, 97–99, 101–102

ergonomics and worker capability strategies, role in, 36, 38

high-hazard, high-risk activities, 25

high-risk patients, safety climate, and worker stress, 11

medical conditions and health risks, 1

musculoskeletal injury risks, 63

nursing workforce and bullying, harassment, and horizontal

violence, 98

patient outcomes, role in, 11, 12

patient safety programs, management systems, and involve-

ment of, 31

safety and health management system, role in, 28

safety improvement, staff engagement in, 50–51, 132–133

support system for staff following errors or adverse events,

33, 117–124

Worker safety

coordination of patient and worker safety functions, 26,

30–33, 61

definition of and use of term, 2

dimensions across safety culture tools, 10

growth of interest in, 26

hierarchy of controls and interventions to resolve risks,

34–35, 36, 38

HROs and preoccupation with, 11

performance improvement and coordination of patient and

worker safety issues, 40, 44

responsibility for, 26

ROI and, vii–viii, 11–12

siloed safety programs, vii

synergy and interrelationship between patient safety and, vii,

1, 11, 131–134

Working surfaces, 137

Work Injured Nurses’ Group (WING) safe patient handling

resources, 68

Workplace conditions and quality of work life

adverse event contributing factors, 37

bullying, harassment, and horizontal violence, 97–99

burnout, 27, 51, 111–112, 118

conditions and job demands, fitting to worker capabilities,

36, 38

controls in worker and patient safety, 34, 35

design of for safety, 38

fatigue, workload demands, and staffing levels, 111–117

impact of, 111–112

patient safety and, 112

regulation and strategies to combat fatigue, 112–115

resources, 116–117

shift length and scheduling, 111, 112

worker well-being and patient safety interventions,

113–115

work schedules review and recommendations, 112–113,

114

General Duty Clause (OSHA), 148

hazards and risks, identification of, 38

interventions to improve worker well-being, 113–115

MSD risks, 36

musculoskeletal injury risks, 63

National Healthy Worksite Program (CDC), 58

occupational safety and health research and, 131, 133, 134

patient safety and, 58

perception of by staff, 51

resources, 57–60

safety culture and, 10, 12

Work-related injuries and illnesses. See Emotional injuries and

illness (second victims); Occupational illnesses and injuries

Work-Related Injury Statistics Query System (Work-RISQS),

Worksite analysis, 27, 28, 99

World Health Organization (WHO)

“Draft Guidelines for Adverse Event Reporting and

Learning Systems,” 45

hand hygiene guidelines, compliance with, 32

human factors concept, 36

International Agency for Research on Cancer, 89

radiation exposure risks, 89

sharps injury rates and prevalence, 78

violence, definition of, 95

161

Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation

162

Improving Patient and Worker Safety

Opportunities for Synergy, Collaboration and Innovation

Health care professionals whose focus is on patient safety are very familiar with these alarming

and frequently cited statistics from the Institute of Medicine: medical errors result in the death

of between 44,000 and 98,000 patients every year. Health care professionals whose focus is on

occupational health and safety, however, are likely aware of additional statistics that are less well

known: health care workers experience some of the highest rates of nonfatal occupational illness

and injury—exceeding even construction and manufacturing industries.

What do these statistics tell us about safety for both patients and workers in the health

care environment? Is there a connection between worker safety and patient safety? Are

there synergies between the eorts to improve patient safety and eorts to improve worker

safety? How can improvement eorts be coordinated for the benet of all?

This monograph is intended to stimulate greater awareness of the potential synergies between

patient and worker health and safety activities. Using actual case studies, it describes a range of

topic areas and settings in which opportunities exist to improve patient safety and worker health

and safety activities. This monograph is designed to bridge safety-related concepts and topics that

are often siloed within the specic disciplines of patient safety/quality improvement and

occupational health and safety.

This monograph includes information about the following:

• High reliability in health care organizations and benets to improving safety for

both patients and workers

• Management principles, strategies, and tools that advance patient and worker safety

and contribute to high reliability

• Specic case examples of activities and interventions to improve safety

• Key themes and action steps to meet challenges and achieve success

This monograph was developed in collaboration with the National Institute for Occupational Safety

and Health (NIOSH), National Occupational Research Agenda (NORA) Healthcare and Social

Assistance Sector Council and supported in part by a contract from this program.

Note to readers (2020): The front and back covers of this monograph were updated to adhere

to revised Joint Commission guidance on branding of internally-developed publications. However,

the content has not changed. In recent years, awareness of the inextricable relationship between

safety for workers and safety for patients has grown dramatically. This is evidenced by national

initiatives to enhance clinician well-being and prevent burnout, improve leadership engagement in

sta safety, prevent workplace violence, promote safe patient handling, and advance safety culture

and high reliability. Readers should continue to nd the content and examples of innovative prac-

tices relevant to their eorts to improve safety for both workers and patients.