What is the High Reliability Organization principle “Preoccupation with Failure”?
Preoccupation with failure in healthcare refers to the need for continuous attention to anomalies that could be symptoms of larger problems in a system. High Reliability Organizations (HROs) that demonstrate a preoccupation with failure strive to detect small, emerging failures because these may be clues to additional failures elsewhere in the system. At its root, preoccupation with failure is a mindset that anticipates and specifies significant mistakes that an organization doesn’t want to make.
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Erin Madden, a patient care assistant at Phoenixville Hospital near Philadelphia, made sure that her patient's bed wheels were locked before transferring her patient into bed. The bed moved anyway. And while her patient didn't fall and no harm was done, the incident nagged on Madden's mind.
At her unit's daily safety huddle, she reported her concern about unreliable wheel locks. Her report led to the discovery that more than half of the beds on the unit were unstable even when the wheel locks were engaged. That discovery led to assessment and repair of wheel locks hospitalwide — and to Erin Madden being recognized in the Pennsylvania Patient Safety Authority's annual "I Am Patient Safety" contest in 2017.
This anecdote, in which a relatively low-level care provider recognized the systemic implications of a "near miss" with one patient, illustrates one of the five traits that High Reliability Organizations (HROs) employ in order to operate for extended periods without serious accidents or catastrophic failures: preoccupation with failure.
- The entire staff, from a low-level assistant to the unit-level managers to the hospital administration, recognized the importance of identifying potential safety risks.
- The unit held a daily safety huddle where frontline staffers were encouraged to discuss incidents, observations and concerns.
- The hospital's management took Madden's observation seriously and escalated the investigation facility wide as it became clear that the risk was not isolated.
- The patient care assistant's safety-centered observation -- variously known as a "good catch," "near miss" or "close call" -- was recognized by her employer, which nominated her for the statewide award, which has been used in Pennsylvania since 2013 to recognize active commitment to patient safety.
Preoccupation with failure is not a checklist, although checklists can certainly be part of patient safety. "Preoccupation with failure is a mindset, a way to mindfully organize work, applied by all staff every day on the job," researchers at Johns Hopkins Armstrong Institute for Patient Safety & Quality wrote in 2017.
The mindset that is preoccupied with failure "look[s] for errors rather than assuming what is in front of them is correct," the Armstrong researchers wrote, referring specifically to frontline clinicians. "For example, when nurses conduct a high-risk intravenous medication double check, the second nurse should assume the first nurse made a mistake, hunt for it, and correct it, rather than assume the intravenous pump is working or programmed properly and the medication is right."
This thought process -- something here might harm my patient, and I'm going to find it and fix it -- is a preoccupation with failure. But it does not come naturally; it is a habit that must be taught and reinforced. The Armstrong researchers suggested adding preoccupation with failure to classroom training for health care providers — "For example, in a simulation laboratory students or physicians could identify errors with a mediation pump or a ventilator set up." — and reinforcing the mindset during clinical rotations.
In the health care setting, unit-level managers can continually reinforce the preoccupation with failure during daily huddles or briefings. "Managers can also ask frontline staff that thought-provoking question, how will the next patient be harmed, and use their responses to proactively identify and mitigate those risks," the Armstrong researchers suggested.
Spotting and fixing safety risks before they do harm is not enough. Reporting these near misses or good catches should be seen by frontline caregivers "as equally important in the scheme of event reporting." Why? Because more near misses reported results in fewer serious events in which patients are actually harmed -- the goal of every HRO.
Like preoccupation with failure, reporting good catches must be taught and incentivized. Multiple studies have confirmed that providers report more good catches when they are encouraged to. For instance, the American Academy of Family Physicians National Research Network invited clinicians and staff in 10 family medicine clinics to report errors during a 10-week study. Five days during the study were designated for reporting every error they observed. Ultimately, 37% of the reports were made during the five intensive reporting days.The same is true internally. The Pennsylvania Patient Safety Authority tracked reporting in four hospitals that had good catch reporting systems in place. Between 2005 and 2016, the number of good catches reported by the hospitals increased by more than 60% (from 33,777 in 2006 to 54,472 in 2016) while the number of serious events decreased by 14%.
As the example of the defective wheel lock illustrates, the preoccupied mindset and reporting must be followed up with managerial action. That often includes a formalized data collection process — like American Data Network’s Patient Safety Event Reporting Application — but it can also include the virtuous cycle of recognition that incentivizes more alertness and more reporting that reduces harmful events.
Some health care settings have used internal newsletters to recognize good catches, especially those that have led to systemic improvements. Greater Baltimore Medical Center, for instance, used its MD Today publication for physicians to describe the near miss that resulted in epinephrine and ephedrine no longer being stored next to each other in medication storage areas.
One facility that participated in a 47-hospital Good Catch Campaign led by American Data Network Patient Safety Organization (ADNPSO) offered as part of its recognition program an extra vacation day to quarterly award winners.
Next Steps to Become More Preoccupied with Failure
While there’s no single roadmap to becoming preoccupied with failure, a successful focus on failure often starts with obsessive data scrutiny.
The recommended tactics included below all fall into 3 main categories:
- What does my existing data tell me?
- What data am I lacking and how do I get it?
- What effect does the underlying culture of patient safety and reporting have on the quality and quantity of my data?
To become more preoccupied with failure and begin answering these questions, utilize the 7 free tools and resources available below.
What does my existing data tell me?
- Benchmark Your Event Reporting Rate with this Calculator: A strong culture of event reporting is a foundational building block of an overall culture of safety. But assessing the strength or weakness of your culture of reporting can be challenging. ADN’s Patient Safety Event Reporting Rate Calculator shows how your number of events and near misses reported per number of patient days compares to other hospitals' reporting rates and includes improvement goals and recommended strategies, tactics, and tools based on your rate.
- Catch Failure Hidden in Your Catchall Category of “Other” Event Types: In 2018, ADNPSO conducted a deep-dive analysis of the event type “Other.” Over a four-year period, this catchall category accounted for over 40% of events reported by ADNPSO members. Among the myriad of striking revelations, the death rate of incidents categorized as Other was 3 times higher than ALL remaining event categories combined. Regular analysis of your uncategorized events can provide critical insight into trends and patterns that might otherwise lay hidden.
- Pay Special Attention to Specimens: ADNPSO analyzed 4 years of data and found specimen events consistently ranked among its highest reported errors with 73.7% of the incidents deemed preventable. This led ADNPSO to develop and launch a 9-month Specimen Focused Study aimed at better understanding why these events happen and how to reduce errors across all stages of the Specimen Process (Pre-analytical, Analytical and Post-analytical). Among other successes, participants realized a 147% increase in specimen event reporting during the study and potentially estimated avoidable costs of $420K - $1.04M in just 9 months. Access the free Specimen Error Study Toolkit here.
What data am I lacking and how do I get it?
- Conduct a Gap Analysis on Your Current Event Reporting Process: This easy-to-use, free Gap Analysis Template can help you evaluate your Patient Safety Event Reporting Processes so you can see how well or poorly yours meets the key needs of a high-performing process.
- Get More Proactive with a Good Catch Campaign: A well-run Good Catch or Near Miss Campaign can be an invaluable tool to build trust among quality and safety teams and ultimately a catalyst for decreasing adverse events. Leverage this free Good Catch Campaign Toolkit used in a year-long initiative by 47 hospitals that achieved a 47% improvement in near-miss reporting.
What effect does the underlying culture of patient safety and reporting have on the quality and quantity of my data?
- Assess Your HRO Culture: Utilize this survey toolkit based on a study aimed at creating a tool that helps facilities assess how well or poorly their organization embraces each of the 5 traits of a high reliability organization.
- Conduct Frequent Mini-Patient Safety Culture Surveys: This free Patient Safety “Pulse Check” Survey Toolkit, which includes an automated analytics report, can help your facility gain valuable insight into your progress without having to wait until your next scheduled annual or biennial AHRQ SOPS Survey. Several of the 15 questions in the survey, developed by the Veterans Health Administration (VHA) National Center for Patient Safety, will shed light on how failure is perceived and addressed in your organization.
- Encourage Leadership to Conduct a Culture of Safety Self-Assessment: The American College of Healthcare Executives developed a self-assessment tool for leadership teams to assist organizations in their quest to develop a culture of safety. The survey is organized into six leadership domains: (1) Establish a compelling vision; (2) Build trust, respect, and inclusion; (3) Select, develop, and engage your Board; (4) Prioritize safety in the selection and development of leaders; (5) Lead and reward a just culture; and (6) Establish organizational behavior expectations. ADN packaged this self-assessment in an easy-to-use survey and automated analytics report your organization can use.
For more examples and anecdotes of notable good catches, see the Pennsylvania Patient Safety Authority's annual "I Am Patient Safety" awards, which include brief descriptions of the award winners:
About American Data Network
For more than 25 years, American Data Network (ADN), which is also the parent company to its Patient Safety Organization (ADNPSO), has worked with large data sets from various sources, aggregating and mining data to identify patterns, trends, and priorities within the clinical, financial, quality and patient safety arenas. ADN developed the Quality Assurance Communication (QAC) application, with which hospitals, clinics, rehabs, and other providers record and manage patient safety events. By entering events into ADN’s QAC application and submitting them to ADNPSO, information is federally protected and thereby privileged and confidential. These protections provide a safe harbor to learn from mistakes and improve patient safety.