Moving From a Culture of Blame to a Culture of Safety in the Nursing Home Setting

Headnote

TOPIC. A culture of safety.

PURPOSE. To explore the current culture of blame and what organizational elements must be impacted to move toward a culture of safety in the nursing home setting.

METHODS. A mixed-method approach incorporating a case study and staff member survey results were used to explicate the organizational elements impacting the current nursing home culture.

CONCLUSION. Nurse leaders can create an environment in which every member of the team feels a responsibility and an ability to insure that residents are safe by improving communication and participation in decision making.

Search terms: Culture of safety, medication error, nursing home

Introduction

Medical error experts estimate that more than 50,000 patients die each year from preventable errors, suggesting that preventable error in the healthcare system is the eighth most common case of death (Institute of Medicine [IOM], 1999, 2001, 2004; Leape, 1994; Sexton, Thomas, & Helmreich, 2000). Furthermore, within preventable error statistics, it is not known how often unexpectedly poor response to treatment could be due to undetected omission of medications, wrong medications, or receipt of a wrong dose. Research suggests that medication errors average 10% or more of administered doses, excluding wrong time errors (Allan & Barker, 1990; Barker & Allan, 1995).

The nursing home provides care to some of our nation's most frail and vulnerable citizens with whom even relatively minor medication discrepancies can have very negative outcomes (Bates et al., 1995). Medication administration in the nursing home is often viewed as a routine and basic task. In reality, the administration of medications in the nursing home reflects a complex interaction of a large number of specific decisions and actions (Kaushal et al., 2001) often performed under less than ideal conditions by staff members representing diverse roles such as certified medication technicians, licensed practical nurses, and registered nurses (Vogelsmeier, Scott-Cawiezell, & Zellmer, in press). Providing safe medication administration in the nursing home setting requires a well-designed medication delivery system, mindful staff members, and an environment in which concerns related to medication delivery can be discussed for ongoing improvement to occur. An environment conducive to open dialogue to facilitate safer practices is often referred to as a culture of safety.

The development of culture of safety among healthcare settings was recently addressed at...