Context for a Healthcare “Culture of Safety” and the Need for Quality Improvement

In 1999 the Institute of Medicine (IOM) published a report titled: “To err is human: building a safer health system” (Poillon, 1999). The paper reported groundbreaking statistics, which identified hospitals as one of the most dangerous places in the United States due to medical errors. The report detailed the detrimental impacts of medical errors including patient deaths, financial impacts, and loss of trust in the healthcare industry.

The IOM report identified major issues in medical systems including: lack of communication among providers, lack of incentives for improving quality and safety, and flawed systems. The report distinguishes that rather than individual person errors, most medical errors are a result of system issues. The report encourages national level changes including: a federal level focus on improving patient safety, mandated reporting of medical errors, improvements to standards of care on a national level, and a culture of safety across all medical institutions. As learned through the IOM report, system-wide initiatives and quality improvements are crucial to creating a culture of safety in healthcare institutions.

After the publication of the IOM report, healthcare research related to patient safety increased. Along with an increase in safety literature, the IOM report also propelled a shift in the kind of safety research conducted. Whereas before the release of the IOM report most research centered on individual blame and malpractice cases, research began to focus on system-wide causes for a lack of safety (Stelfox, Palmisani, Scurlock, Orav & Bates, 2006). Although the IOM report brought attention to the issue of patient safety, much like at the time the report was published the healthcare industry continues to struggle today in improving safety (Free from harm, 2015).

The importance of quality improvement and safety in medical radiation technology cannot be overstated. Both components are integral to ensuring positive patient outcomes, optimizing benefits to healthcare providers, and positively impacting the broader healthcare system. These components directly impact patient satisfaction and healthcare delivery.

Quality improvement refers to systematic, data-guided activities designed to bring about immediate, positive changes in healthcare delivery. In the context of imaging care, it involves improving the efficiency, effectiveness, and versatility of healthcare delivery.

Safety in diagnostic imaging involves minimizing the risk of unnecessary harm associated with healthcare to an acceptable minimum. This includes potential falls, radiation exposure, and poor communication risks.

As the push for improving patient safety in healthcare continues, leading healthcare systems are expanding safety initiatives to incorporate employee safety. Employee safety is both cost-effective for the organization as well as serving as a contributor to patient safety (Organizational Safety Culture-Linking Patient and Worker Safety, n.d.). In order to improve both patient and employee safety in healthcare institutions, a culture of safety is a requirement. A culture of safety may be defined as an organizational ideology, which prioritizes safety over financial gain or benefit (Creating and sustaining a culture of safety, 2004).

Several models of quality improvement are used in healthcare, such as the Plan-Do-Study-Act (PDSA) cycle, Six Sigma, and Lean. These models help organizations identify areas for improvement and systematically improve their processes for better outcomes.

Several tools are used to effectively carry out quality improvement and safety initiatives. These include the Root Cause Analysis (RCA), which is a systematic process for identifying the root causes of problems or events and an approach for responding to them. The Failure Modes and Effects Analysis (FMEA) is a step-by-step approach for identifying all possible failures in a design, a manufacturing or assembly process, or a product or service. Checklists are another common tool used to ensure consistency and completeness in carrying out tasks.

MRTs play a vital role in these initiatives. They are on the frontlines of patient care, making them integral to ensuring quality and safety. Their roles include patient advocacy, effective communication, continuous learning, and self-improvement.