In Pennsylvania, one of the first ways healthcare facilities respond to an adverse event is by submitting a report through the PA-PSRS system. However, we not only want you to submit a report, but to learn from your experiences and from others’ best practices. That’s why we designed PA-PSRS to help promote a culture of safety by facilitating report analysis and internal quality improvement. These Advisories also serve that purpose. In our recent User Survey, 74.5% of hospitals reported having made changes within their facilities as a result of articles in the Advisories.

Under Act 13, facilities are also required to respond to adverse events by notifying a patient about a Serious Event. While several studies validate the importance of acknowledging, as well as apologizing for, adverse events, providers and managers continue to wrestle with how they should implement this disclosure requirement.

In a previous column, I wrote about the disclosure requirements of the U.S. Department of Veterans Affairs for all federal Veterans healthcare facilities. I also cited a recent article by Dr. Lucian Leape specifically addressing physicians on this important issue (Vol. 2, No. 4—Dec. 2005).

Earlier this month, Harvard-affiliated hospitals released a “Consensus Statement” entitled When Things Go Wrong: Responding to Adverse Events. This statement is likely to influence health policy makers around the country and is now established in the 16 Harvard teaching hospitals, including such renowned institutions as the Brigham and Women’s, Dana-Farber Cancer Institute, Joslin Diabetes Center, Beth Israel Deaconess Hospital and Massachusetts General. You can access this document at the website of the Massachusetts Coalition for the Prevention of Medical Errors at www.macoalition.org/index.shtml.

In the same vein, I encourage you to consider the “Sorry Works!” initiative, which is being adopted by an increasingly large group of hospitals and systems around the country. See www.sorryworks.net for more information about this successful initiative.

While the action of reporting an adverse event involves only staff and administrators at a particular facility, the process of disclosure engages the patient and his family as well. Establishing a “Just Culture Community” expands the entities involved to include organizations and agencies external to the healthcare institution.

At the recent 2006 Patient Safety Symposium sponsored by HAP (Hospital and Healthsystem Association of Pennsylvania), the Authority was pleased to underwrite David Marx’s keynote address on “Patient Safety and the ‘Just Culture’.” An engineer and attorney with experience in aviation safety as well as healthcare, Marx expands the traditional definition of patient safety to mean not only freedom from injury or harm, but freedom from the risk of injury or harm.

During his talk, he challenged the audience of almost 400 to encourage traditionally competing groups to agree on a common response to adverse events. Marx noted that, in Minnesota and several other states, the hospital association, state health department, and the nursing and medical boards are striving to establish a “Just Culture Community” by agreeing that, in exchange for full and open disclosure by providers, the regulatory agencies would refrain from disciplinary action following an unintended adverse event not caused by reckless or risky behavior.

What makes this process work—requiring provider disclosure in exchange for regulatory restraint—is a commitment by providers to individual and institutional accountability. This innovative, if nontraditional, approach is built upon Marx’s concept of a “just culture,” which blends accountability with system reliability. To learn more about the concept of “just culture,” go to www.justculture.org.

How you respond to an adverse event defines how willing you and your facility are to adopting a culture of safety. Full disclosure, open dialogue, accountability, learning-- these are the components of patient-centered care. And that’s the bottom line for all of us, providing safe, effective and quality healthcare for patients and their loved ones.

Alan B.K. Rabinowitz
Administrator
Patient Safety Authority