How many quality improvement projects are going on in your organization right now? How many committees are devoted to improving safety? If you're like most facilities, there are probably dozens. Across the country, countless hours are devoted to preventing errors that harm patients through creating checklists, protocols, automated systems, and the like.
Are they worthless?
That's what I started wondering when I came across a new study that examines why poor communication is still the biggest patient safety danger of all.
The report is a combined effort from the American Association of Critical-Care Nurses (AACN) and the Association of periOperative Registered Nurses (AORN) in partnership with VitalSmarts, a training and organizational performance company. AACN and VitalSmarts produced the seminal "Silence Kills" data five years ago that found:
The 2006 data greatly enhanced our conversations about how to improve safety and led to efforts such as AACN's healthy work environment initiative that has been adopted by many organizations.
Wanting to see what's changed in the last five years, the organizations, joined by AORN, conducted another study that surveyed 6,500 nurses and nurse managers. The data revealed some alarming statistics, released in a report "The Silent Treatment." Eighty-five percent of respondents said a safety tool had alerted them of a problem that might have been missed and potentially harmed a patient and yet 58% percent revealed they didn't say anything about it.
Among the study's key findings:
"Safety tools such as protocols and checklists guard against honest mistakes," says AORN Executive Director/CEO Linda Groah, RN, MSN, CNOR, CNAA, FAAN. "However, this study tells us there is more work needed in the OR to support the surgical team's ability to establish a culture of safety where all members can openly discuss errors, process improvements, or system issues without fear of reprisal."