Journey To Zero

Written by Jonathan White on 2/12/2023

High Reliability Organization Training Prevents Safety Events

NEJM recently published the results of the SafeCare study that looked at the incidence of adverse events during hospitalizations. In a random sample of 2800 admissions, at least one adverse event was found in 23.6% of those admissions. Preventable adverse events were found in 7% of all admissions, with these preventable errors being serious or fatal 1% of the time. That may not sound like many patients, but this would not be tolerated in other industries. Can we imagine feeling safe with nuclear power plants that have serious adverse events happening almost 25% of the time? Would you want to fly with an airline with preventable adverse events occurring in 7% of all their flights?

Hospitals should be the safest places on earth however, as you are all aware, there are many sources of error. As Dr. Glen Cobb, infectious diseases at UAB, used to say, “hospitals are bad places for sick people to be.” So much can go wrong when a day in the hospital requires the coordination of dozens of people, including EVS, lab, nursing, imaging, transport, pharmacy, IT, etc.

In 2019, Huntsville Hospital started training staff to operate as a “high-reliability organization.” Examples of high-reliability organizations include air traffic control systems, nuclear power plants, and other organizations that require high-performance processes to prevent disaster. These types of organizations use processes that we at Huntsville Hospital can use to improve patient safety. Organizations that diligently follow these principles have experienced an 80% decrease in serious safety events. Some examples of these high-reliability principles used by our staff include the following:

Nursing communication through SBAR format.
Crosschecking
Speaking up using ARCC
Keeping attention on task with STAR
Situational awareness through a daily Safety Call

Many other HRO principles are being used every day at Huntsville Hospital. These tools are helping prevent harm to our patients, but more must be done. If you would like to be trained for the first time or go through a refresher, training sections are available through our Quality Management department. Call them at (256)265-2745 to find out more regarding HRO training.