Does your culture squelch or embrace staff's natural "preoccupation with failure?"

NOTE: Among the many management tools, techniques and approaches that health care organizations have co-opted from other industries during the past two decades, "high reliability organization," or HRO, theory is unique. This research, which was spearheaded by Karl Weick from the University of Michigan in the 1970s, helped identify five organizational characteristics that contribute to avoidance – or at least containment – of catastrophes in environments where accidents can be expected due to high risk factors and complexity:

• Preoccupation with failure
• Reluctance to simplify
• Sensitivity to operations
• Commitment to resilience
• Deference to expertise

This is the second in a series of articles highlighting communication practices that promote the five HRO characteristics that create a culture of safety and reliability. This month we focus on the first principle of anticipation: a preoccupation with failure.

"What if I miss something or make a mistake?"

It is a fear often verbalized by young nurses but shared universally by health care professionals regardless of their level of training or years of experience.

Of all of the HRO principles, health care professionals naturally possess the mindset that captures the essence of "preoccupation with failure" more than any of the other four characteristics. Unfortunately, many organizations unintentionally suppress healthy discussion of this innate concern by directly or indirectly communicating that, "You can't make a mistake."

The following recommendations can help reopen the conversation around potential failure and foster a culture that collaboratively finds ways to prevent it.

Health care organizations years ago embraced the philosophy that the first step in better error prevention is better error reporting. But despite more diligent reporting and the creation of elaborate databases filled with incident reports, many hospitals do not leverage this trove of insightful information. Too often trend results by unit are not reported consistently to frontline staff. And when trend reports are shared, they are too often accompanied by a version of the admonition, "let's not do this anymore," rather than with a collaborative, structured effort to systematically prevent failure.

When managers communicate error trend data on a regular basis and encourage dialogue around the causes and potential solutions to prevent failure, they do more than just uncover more effective, safe practices and processes; they foster a culture where staff feel equipped and empowered to identify and fix conditions that could result in errors if left unchecked.

Psychologically, there is a big difference between a great catch and a near miss in patient care. But in practice they must be looked at in the same light: a defect in process or practice that has the potential to cause harm to a patient next time.

It is fine to praise an individual who makes a good catch. But a manager's response for his/her team must be to stimulate dialogue and problem-solving to prevent the near miss from becoming a tragic error.

Additionally, near-miss prevention means that reporting and trending of these incidents is just as important as reporting errors. If your system does not accommodate and encourage good-catch reporting, you are missing important opportunities to prevent failure.

While not intentional, waiting for an error or even a near miss to occur before doing something about a high-risk defect in process sends all the wrong messages to frontline staff. Devoting time to the discussion and identification of potential flaws in practice is essential to changing the culture to embrace a healthy preoccupation with failure. Thought-provoking, open-ended questions designed to encourage candid discussion can be one of the best ways to move the culture forward.

• What aspects of your job, especially related to patient safety, keep you up at night?
• How would you fill in this blank: "When things get especially hectic in our department, I worry most about _____________"
• Are there certain practices or processes that we all do differently? Are there ways that some of your colleagues do certain things that concern you or that you have questions about?
• What specific tasks or procedures that you perform often leave you quietly thinking, "I hope I'm doing this right?"

Because health care professionals already have a natural inclination to be preoccupied with the fear of making a mistake, an organization's challenge is to move unproductive fear to constructive action. Consistent reporting, candid dialogue and inclusive problem-solving are the best ways to reinforce that conditions which increase the risk of failure can be significantly reduced or even eliminate by communicating openly and working together.

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