SPEAK UP Staff need administrative support to feel free to voice concerns when they see situations that could jeopardize patient safety.

Any OR leader would say even one surgical error is one too many. But how do you get to zero avoidable errors? Sue Dill Calloway, RN, AD, BA, BSN, JD, CPHRM, CCMSCP, says it begins with having an environment where all staff are encouraged to voice their concerns — and feel comfortable doing so — whenever they see a potentially unsafe situation.

Not everyone does, she says, using safe injection practices as an example. Nearly 40% of healthcare professionals who participated in a 2013 Institute for Safe Medication Practices survey said they often felt too intimidated to ask questions or seek clarification over medication orders, even if doing so could have prevented an adverse event.

"If you don't have a culture where people can speak up, you're never going to find out how to fix the problem," says Ms. Calloway, president of Patient Safety and Healthcare Consulting and Education in Dublin, Ohio.

Her point: Creating a open, fair and just environment in which staff can report and discuss errors is no easy task, especially considering historical OR hierarchies, but it's an essential one. Where to begin? Follow these 6 steps.

1. Start at the top. Without administrative support, staff won't feel encouraged to speak up when they see behavior that could endanger a patient's safety. Ms. Calloway uses the example of a nurse refusing to hand a surgeon a scalpel when he hasn't completed a proper time out. "He might run to the administration and say the nurse is keeping him from doing the surgery," she says. "When there's a culture of safety in place, the administration might respond by asking, 'Did you do a time out?' He'll answer, 'Well, no.' 'Then you can't have the scalpel.' If the staff doesn't get that kind of support, they wouldn't feel comfortable doing that."

SAFETY CULTURE In this infographic, The Joint Commission outlines what healthcare leaders must do to promote and support safe practices.

2. Break down barriers. Establish an inter-professional task force to meet about "culture work" often, if not daily, says Ramon Berguer, MD, FACS, the former chief of surgery at Contra Costa Regional Medical Center in Martinez, Calif. Dr. Berguer, who for 11 years served on the Committee on Perioperative Care of the American College of Surgeons, says it's helpful if these individuals have some background or education in patient safety. Also, he says a mediator might be helpful to iron out any substantive differences.

Jennifer L. Fencl, DNP, RN, CNS, CNOR, the clinical nurse specialist and interim executive director for clinical support and research at Moses H. Cone Memorial Hospital in Greensboro, N.C., says inter-professional education has helped her organization bypass "a huge roadblock" in regard to preventing wrong-site surgeries.

"Typically, nurses will educate nurses, surgeons will educate surgeons, and anesthesia will educate anesthesia," she says. "In that kind of framework, we've already built silos. We need everyone to hear the same message."

As part of efforts to break down those barriers, Cone Health created a time-out and debriefing video featuring "the whole complement of the team" that is viewed by surgeons, anesthesiologists and nurses. The video illustrates how a time out should look — and also how it shouldn't, with music blaring and casual conversation distracting team members — with standardized dialogue among team members to articulate patient safety concerns.

3. Provide a framework to help staff succeed. Just telling staff they need to speak up isn't enough; they also should be given the tools they need to do so, says Ms. Fencl. Her organization's C.U.S. model — short for "I have a Concern; I'm Uncomfortable; Stop, this is a safety issue" — provides this guidance, complete with role-modeled scenarios staff might see in the OR. The team also developed protocols for dealing with what happens next. "Before, when we had an event or a near miss, we would pull a couple of stakeholders aside and talk about it so we could identify something that needed to change," says Ms. Fencl. "That was all good, but now we say, 'Let's step back and have a comprehensive evaluation of the practice we have in place.'"

4. Focus on systems, not people. Reprimanding an employee who makes a mistake might address a single incident, but it won't solve a systemic problem. That's why Ms. Calloway is a proponent of Just Culture (osmag.net/J7nHdF), a framework for helping organizations achieve what she calls "balanced accountability."

Rather than a blanket approach, Just Culture recognizes the differences between human error (accidentally placing an unsterilized instrument on a tray or inadvertently using a look-alike, sound-alike drug, for example), at-risk behavior (taking shortcuts with disinfection protocols between cases) and reckless behavior (ignoring required safety steps, such as moving forward with a surgery without conducting a proper time out). Put another way, it's designed to help healthcare providers learn from their mistakes — regardless of whether those mistakes resulted in patient harm — not dole out punishments to the guilty. "It really doesn't matter what the outcome is; you're looking to adjust the behavior," says Ms. Calloway.

5. Recast your priorities. Adopting a culture of safety will challenge the deeply engrained OR mindset centered on performance. "A classic example is the temptation to skip correct site marking and patient identification in the name of speed and efficiency," says Dr. Berguer. "That's not a problem 99 times out of 100, but for that 100th time, it is going to be a problem — and it's going to be catastrophic." Although any newly adopted measures might feel awkward and even intrusive at first, they'll quickly become part of the routine, says Dr. Berguer, much like putting on a seat belt when you first get into your car.

6. Be flexible. Even the most airtight safety protocols will face challenges. "Usually it's some hole we hadn't foreseen or a collection of circumstances that occurred, so we'll do a root cause analysis and might have to go back and amend the protocol," says Dr. Berguer.

This reminds him of a consulting surgeon who came to the OR to assist with a complex case. Although the house surgeon fully understood the nature of the surgery, the consulting surgeon had prepared for a different operation on a different patient. The facility has since adopted a 3-step process designed to avoid such near misses:

• a sign in to confirm patient, procedure and consent, among other things, prior to induction;
• a time out just before incision; and
• a sign out after the incision has been closed to confirm patient name and ?procedure, instrument count, and review of anticipated recovery issues and equipment problems. OSM