Safety starts here...with systems thinking

FigureSAFETY REMAINS TOP OF mind for all of us in health care. This month is Nursing Management's annual, award-winning safety issue, featuring insights from our authors in the ongoing quest for quality and safety in patient care delivery and in our environments of care. Many would debate whether patient care or the environment of care is safer now than 10 or even 20 years ago, for a multitude of reasons, including complexity, workforce shortages, teamwork failures, the entire continuum of workplace violence, and lack of safety cultures. Which brings us to a fundamental starting point that the late Lucian Leape taught us many years ago but which we still struggle to embrace: a focus on systems, not individuals. Dr. Leape, who passed away this year, is often called the father of the modern patient safety movement for his influential work following the release of the Institute of Medicine's infamous 1999 report on the number of patient deaths from preventable patient harm. He was one of the few who argued at the time that patient harm wasn't inevitable or even acceptable. He was dedicated to system-level transformation, including concepts such as the importance of leadership as a driver, and workplace respect, health, and safety, including psychological safety. Punishing individuals wasn't his style. His trailblazing positions are still top of mind today. Systems thinking means asking why and how, not who, and understanding what drives behavioral choices. Simply asking if anyone else could've made the same decision or taken the same action under the same circumstances (the substitution test) is revealing; if the answer is yes, then you have systems to fix. Leadership holds the responsibility to address systems issues, and as nurses, we should leverage our trust in our clinical colleagues to actively engage them in identifying solutions. When you develop corrective action plans following analysis of a safety event, or even proactively as many forward-thinking organizations do, is the plan focused on systems or people? The hierarchy of effectiveness ranges from very low value, which focuses on people (such as telling someone to be more careful, retraining, or writing policy) to much higher success by focusing on systems (such as standardization, simplification, or forcing functions—think different connectors for IV and gastrointestinal tubing). These higher-level and stronger interventions are using systems thinking and acknowledging complexity, which is harder and takes longer than writing another policy. And that policy rarely improves safety unless it's implemented with fail-safes, streamlined processes, and/or automation. Another hurdle to quality and safety is how we organize projects in their own silos. You don't want your clinical staff and providers spinning in an onslaught of new and seemingly unrelated expectations. Optimize workforce and clinician engagement by integrating and modeling safe culture values in everything you do, such as ownership, learning, transparency, and respecting each person's value. It goes without saying, but it's often forgotten: the nurse is frequently the last line of defense against error. I was reminded of this critical nursing role by a dear colleague with an extensive background in quality improvement. Yes, that last line of defense is an individual. And that person is working within a system that either supports or doesn't support safe behavioral choices, identification of risk, potential for error, and speaking up. When we move past blame, embrace complexity, seek to learn, and redesign stronger systems, we honor Dr. Leape's legacy and unlock patient care improvement. Start here...with systems thinking.Figure