Safety Mentors Create Culture to Reduce Adverse Events and Increase Error Reporting

Problem Addressed

• Limitations to proactively addressing safety issues: Health care organizations that embody a culture of safety encourage individuals to report errors and near misses and use the associated data to identify problems and implement process improvements to address them.²  In contrast, a "blame-and-shame" organizational culture acts as a barrier to safety improvement, focusing on punishing the individual at fault rather than identifying and addressing system defects that led to the error.³  
• Reluctance to report errors: A 2001 internally developed patient safety culture survey conducted at Christiana Care Health System found that employees felt that reporting an error was difficult and expressed fear of disciplinary action or personal liability if they did so. Only 55 percent of respondents believed that error reporting was widely encouraged and nonpunitive, while 53 percent did not believe that the organization improved patient care in response to medical errors.

Description of the Innovative Activity

• Safety mentor appointment: Each unit and department appoints a front-line staff member to serve as the safety mentor; there are currently 75 mentors throughout the organization. Mentors come from many disciplines, including (but not limited to) nursing, respiratory therapy, laboratory, home care services, environmental services, pharmacy, and radiation oncology.
• Mentor resources and tools: Each mentor receives a guide that provides information and tools regarding patient safety, including an overview of the patient safety movement; descriptions of mentor roles and responsibilities; copies of practice tools used by Christiana Care to facilitate patient safety; references on event reporting process (called Safety First Learning Reports); and contact information for internal and external patient safety resources, personnel, teams, and unit-based medical directors. (Additional information on mentor training can be found in the Planning and Development section.)
• Bimonthly meetings: Mentors attend bimonthly meetings facilitated by Christiana Care’s patient safety program manager, the corporate director of Patient Safety and Accreditation, and the chief medical officer. Meeting activities include:
  • Data sharing: Data gathered as an integral component of organizational efforts to monitor specific safe practice behaviors is shared.
  • Presentations: The patient safety program manager and leaders representing key facets of the organization share stories and lessons learned from Safety First Learning Reports analyses, including near misses.
  • Dialogue on patient safety challenges: Mentors share stories about efforts to engage patients in their own care, patient safety challenges they have faced, staff concerns about error reporting, and feedback and followup of previously identified issues.
• Promoting safe practices with front-line staff: Safety mentors promote safe practices within their own units in several ways:
  • Emphasis on safe practices: Mentors help unit staff design and implement strategies to overcome unit-specific barriers or challenges to safety. Mentors also serve as liaisons between units and organizational safety teams to promote the Joint Commission’s National Patient Safety Goals.
  • Monthly monitoring: Mentors track patient safety behaviors (as specified by the National Patient Safety Goals) on the unit, provide peer-to-peer real-time feedback on the performance of their department or unit, and submit monthly reports.
  • Dissemination of information: Mentors share information, data, and stories discussed at bimonthly meetings with staff at unit meetings. Mentors also share reports of unit and organization performance on the National Patient Safety Goals and discuss Safety First Alerts (periodic notices describing a particular safety concern and associated safe practices) with staff.
  • Error reduction and reporting: Mentors identify safety issues on the unit, communicate them to the staff, and work with staff to implement changes. Mentors identify peers who exemplify safe practices and work with those who require assistance. Mentors also encourage staff to report near misses or potential safety hazards via Christiana Care’s SAFE Hotline, or by completing the online Safety First Learning Report on Christiana Care’s internal Web site.
• Creation and distribution of safety tools: Mentors participate in the creation and/or dissemination of safety initiatives and communication tools, such as an educational video illustrating a “read-back” process for confirming telephone orders; SBAR (situation, background, assessment, and request communication); and DATAS (demographics, assessment, tests, alerts, status) pocket cards that reinforce best practices at the unit level. SBAR is an externally developed communication tool that prompts front-line staff to effectively exchange patient information; DATAS was created by Christiana Care to prompt nursing staff to communicate all relevant information during shift-to-shift and unit-to-unit patient handoffs. 

References/Related Articles

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Results

• Improvements in safety culture: Data from the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture demonstrate that, in 2006, 28 percent of respondents feared disciplinary action in response to a medical error, a dramatic decline from the 76 percent reporting such fears in 2001. Qualitative evidence suggests that front-line staff believe they are learning from their errors, and that positive process changes have been adopted as a result of better identification and reporting of errors.
• Fewer serious adverse events: The rate of adverse events with major outcomes decreased by 8 percent, from 1.21 to 1.12 per 1,000 patients. 
• Improved reporting of medication-related near misses: Christiana Care is catching more near misses related to potential medication errors, and/or reporting more such instances. Reported near misses increased from 46 in 2003 to 85 in 2006. The proportion of reported medication-related near misses to total reported events increased from 0.6 percent in 2003 to 1.3 percent in 2006.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Conducting literature review: The patient safety committee reviewed literature regarding communication between front-line staff and hospital administration regarding patient safety issues and patient safety ambassadors.
• Defining the mentor role: The patient safety committee and representatives from different disciplines formed a focus group that defined the roles and responsibilities of the safety mentor position.
• Gaining organizational buy-in: The patient safety committee approved the safety mentor role description and then shared it broadly throughout the organization to build awareness among front-line staff, unit managers, and senior administrators.
• Creating resource guide: The patient safety committee created the previously described information guide that includes resources and tools regarding patient safety.
• Initial selection and training of mentors: Each unit/department manager selected a safety mentor based on the role description as well as the mentor’s natural ability to lead and influence peers. Those selected received training during a 1-day formal session led by the patient safety committee. Topics covered during the session included the organization’s patient safety activities and goals, safety mentor roles and responsibilities, the use of safety tools, and an introduction to the resource guide.

Resources Used and Skills Needed

• Staffing: As noted earlier, 75 Christiana Care staff currently serve as safety mentors. Mentors typically have a minimum of 6 months’ experience on the unit, knowledge of unit and employee patient safety activities, excellent communication skills, an ability to collaborate with and inspire confidence in others, and a desire to learn.
• Costs: Development and implementation costs were minimal, as the program uses existing staff resources. However, Christiana Care budgets a monthly administrative day for nurses serving as safety mentors; they can use part of this day to fulfill their safety mentor responsibilities as well as other administrative responsibilities. Other safety mentors incorporate their safety mentor duties into their daily workload. Other expenses include catering costs for the lunch provided at monthly meetings.

Funding Sources

Christiana Care Health System

Tools and Other Resources

Getting Started with This Innovation

• Select mentors carefully: Choose safety mentors who have earned the confidence and respect of their peers and who communicate with them in a nonthreatening way.
• Strive for transparency: Make all organizational patient safety data and stories very clear to mentors, who can then communicate these policies to unit staff. Share data freely to encourage the continuation of positive trends and to leverage learning opportunities offered by negative outcomes.
• Consider accommodations for additional work involved: If safety mentors are to take their responsibilities seriously, they may need “protected time” to complete these duties.
• Act on front-line input: Encourage safety mentors to get feedback from front-line staff and use it to improve safety practices. Eliciting and acting on input will show front-line staff that they are making a difference in patient safety.

Sustaining This Innovation

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