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Establish a Learning Culture to Help Prevent Errors in Healthcare

safety huddles log image for performance health partners

Having a well-developed and established learning culture can help prevent errors in healthcare and improve overall patient safety.

Evaluating Trends to Increase Learning Culture Outcomes

People make mistakes. To help prevent errors in healthcare from happening, leaders must create an environment where learning is a priority and provide their team with the right tools to succeed.

An incident reporting software can help by allowing leaders to identify areas of patient risk and to prioritize resources and training around the risk to achieve safer patient care by preventing the same errors from reoccurring.

Developing a Learning Culture Starts with Leadership

It is the responsibility of leadership to not only analyze patient safety reports but also actively ask their team questions and take the appropriate actions based on their answers. (1)

Questions can include: 

  • “In the last few weeks, have you been presented with a difficult patient situation, and how did you handle it?” 
  • “How can the leadership team support you better during this time?” 
  • “How can we prevent this from happening again in the future?” 
  • “Any further suggestions to help prevent future errors?"

Leadership engagement supports a culture of safety by reassuring staff that their feedback matters and that they should speak up when they have a concern.

Best Practices for Establishing a Learning Culture

1. Engage Patients in their own Care

Patient involvement in their own care has, in recent years, been recognized as a key component in the avoidance of unnecessary harm and safety events. (2) Patients should be given educational material upon admission on the standard safeguards and care they should expect to receive. Additionally, they should be informed about routine procedures such as hand hygiene or verifying their name and date of birth before being administered a medication or treatment.

Patients will receive safer care because they are empowered with the ability to ask the right questions and identify gaps in safety. This shift of power supports ongoing learning conversations between patients, their caregivers, and the organizations that serve them.

2. Use Learning Boards to Promote Transparency

Learning boards can guide staff through specific activities that help achieve operational success while improving learning. (3)

Learning boards are digital or analog whiteboards used to visually display key processes, measures, and improvement tests at the unit level. (3)

Teams should be encouraged to use learning boards in patient rooms to accomplish a specific goal. For example, if the goal is to decrease surgical site infection, the learning board should highlight key steps such as:
  • When to administer the appropriate antibiotics
  • When to change wound dressings
  • Anticipated discharge date

Checking a communication board should be incorporated into daily rounding processes for all supervisors as it promotes transparency by offering a way to observe the learning process as it is in action.  

3. Cultivate an Environment of Collaborative Learning

Learning becomes more effective and employee retention is higher when staff takes on a dual role of both the student and the teacher.

During weekly unit safety huddles, teams can implement role-playing to identify subtle patient changes before they lead to serious issues. (4) This exercise can take as little as 5 minutes and have major effects on the safety culture process and a big impact on helping prevent errors in healthcare.

Set the scene for the huddle role play then select 3 volunteers to read scripted roles as a patient, nurse, and physician. After the role-play is complete, practice using a discussion guide to examine the risk factors and interventions that helped prevent a negative patient outcome in this situation. (4)

4. Provide Easily Accessible Employee Training

In addition to regular meetings for scenario-based learning, employees should have a platform for training that is accessible 24/7. 

Centrally locate recorded videos, written guides, and PowerPoint presentations to not create any additional barriers in the learning process. This enables workers to invest their time into developing new skills when it is most convenient for them.

5. Provide Real-Time Access to the Care Experience with Digital Software

A learning culture should have the ability to continuously capture and deliver the best evidence for supporting management decision-making. Paper-based records and reporting impede timely reflection and opportunities for growth. (5) 

Digitizing this data and knowledge can make decision-making and care delivery adjustments quicker and safer for patients, therefore helping to prevent errors in healthcare. (5) Using  Patient Safety Technology can help leadership teams track harm in real-time and identify reoccurring trends. This allows data to be organized in ways that highlight areas of improvement while teaching caregivers how to prevent future incidents before they occur.

Help Prevent Errors in Healthcare with Performance Health Partner’s Solutions

By centering patient safety programs around a learning culture, healthcare organizations across all sectors can provide the highest quality care in the safest possible environment. 

Performance Health Partners’ incident reporting software helps build a culture of patient safety and quality. Learn more about Performance Health Partner's incident reporting software or schedule a free demo!

Request a Demo

References: 

  1. http://www.ihi.org/communities/blogs/how-to-build-a-whole-system-quality-learning-organization-culture
  2. https://psnet.ahrq.gov/primer/patient-engagement-and-safety
  3. http://www.ihi.org/communities/blogs/_layouts/15/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=372
  4. http://www.hqi.solutions/wp-content/uploads/2018/11/The-Huddle-Mtg-RolePlay_final.6-30-17-_508.pdf
  5. https://www.nap.edu/read/25152/chapter/10#275

 

 

 

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