Even a decade after the Institute of Medicine’s (IOM) disturbing report, “To Err is Human: Building a Safer Health System,” recent literature tells us that leaders of behavioral health organizations lack the necessary knowledge base that is needed to implement a full scope of sustainable patient safety initiatives. While many leaders of behavioral health facilities have implemented initiatives to address restraints, seclusion, and suicide, there are a range of other patient safety issues that are unique to behavioral health and addiction treatment. These include: human rights violations, medical and nutritional neglect, human errors, substance abuse, low health literacy, elopement, violent behavior, sexual assault, fragmented/uncoordinated care, and self-inflicted injuries.1
At the same time, behavioral health leaders must be concerned with improving outcomes, providing quality care, minimizing liability exposure, and being named in lawsuits. Schoenbaum and Bovbjerg suggest that behavioral health organizations are commonly sued for improper diagnosing, misdiagnosis, failure to predict risk of suicide, duty to disclose, failure to commit or confine, and negligent release of patients.2
Bates, Shore, Gibson, and Bosk suggest that patient safety issues in behavioral health settings have not come to the public’s attention for four succinct reasons:
1. Invasive procedures are less likely to be performed in behavioral-health facilities;
2. Behavioral health is modal and often solitary—one patient, one physician;
3. There is little access to aggregate safety data, which is essential for quantifying and calling attention to patient safety issues; and
4. Behavioral health and addiction treatment are intensively private, in part because of the need for strict confidentiality.3
Six key steps
Once leaders in behavioral health organizations have identified patient safety issues that are unique to their organizations, the next step is to turn the vision of becoming a patient safety-centered organization into a reality. This goal can be accomplished by simply focusing and educating staff on six core themes. The six themes include:
1. Improving the culture and organizational perception of patient safety;
2. Communicating the organization’s patient safety initiative;
3. Partnering with technology;
4. Appointing a patient safety leader;
5. Mastering the system thinking theory; and
6. Training and development.
Improving culture and perception of patient safety
Improving the organization’s culture and employees’ perception of patient safety are the first steps in building a sustainable patient safety program. According to Singer, Fallwel, Gaba, Meterki, Rosen, Hartmann, and Baker, patient safety culture refers to employees' fundamental ideology and orientation, which explains why safety is pursued in the manner exhibited within an organization.4 Organization leaders at the corporate, facility, and supervisory levels must work diligently to break down internal barriers such as weak top-management support, limited resources, lack of incentives, lack of knowledge, and misunderstanding.5
Communicating the patient safety initiative
The organization’s culture and employees’ perception of patient safety is enhanced when leaders are transparent and communicate the vision effectively. Successful implementation of patient-safety initiatives require leaders to set clear objectives and ensure that staff at all levels within the behavioral health organization is educated on how to communicate openly in a non-punitive manner. Leadership must cultivate an environment where errors or misjudgments are reported frankly and regarded as opportunities for improving processes, increasing knowledge, and engaging employees.
Partnering with technology
Fetter suggests that information technology improves an organization’s patient safety initiatives because it can enhance the quality of care, access, and efficiency.6 Many organizations implement web- or network-based incident reporting and follow-up systems to simplify reporting, tracking, and trending data. Because not all behavioral health workers are technology-savvy, contingency plans for any system should include technology training or other reporting alternatives.
Appointing a patient safety leader
Fukuda, Imanaka, Hirose, and Hayashida advise that the success of a patient safety initiative in any setting is dependent on the support it receives from organizational leaders and their commitment to appointing a patient safety leader who will work diligently to break down the organizational silos.7,8 Thus, the leader of the patient safety initiative should be a part of senior management in order to truly implement change. Leaders are advised to appoint patient safety leaders who can work collaboratively with frontline staff and senior leaders and identify ways to align education with ongoing quality.5,9 Whittington suggests that patient safety leaders should have knowledge of such tools as failure-mode and effects analysis, root-cause analysis, simulation in healthcare, crew resource management, basic human factors, and a process-improvement methodology such as Six Sigma.10
Many behavioral health organizations may opt to add patient safety responsibilities to another job for the sake of having a patient safety leader. However, leaders must recognize that this approach can compromise the level of focus placed on patient safety. Similarly, smaller facilities may consider employing a patient safety leader on a part-time basis. Leaders have to assess what will help them best in their efforts to shift the organization’s culture.