Keeping patients safe from clinical error and unintended harm is a responsibility of every health care professional, system, and organization. While community health care settings have been instituting patient safety concepts since the 1990’s, correctional health care is just beginning to transfer these concepts to the unique setting and patient population of the criminal justice system.

Safety experts in traditional health care settings have established key principles that underlie a patient safety program. Here are some thoughts on how they can be applied in correctional practice.

A Just Culture in a Learning Organization

An organization’s culture is the shared beliefs and meaning of actions that are pervasive among the individuals working within the environment. This culture can be determined by the common attitudes and meanings given to staff actions and the outcomes of those actions. A culture of safety, then, involves shared beliefs among the members that enhance patient safety. Elements of organizational culture found to enhance patient safety include

• Respect and civility
• A regard for safety as a top priority
• Enhanced teamwork and collaboration among all disciplines and levels in the organization
• Openness and transparency about clinical errors when they take place.

The willingness to report clinical error is based on an organizational understanding of the causes of error, as well as the interplay of the environment, clinical systems, health care workers and care recipients. A safety culture seeks to discover and correct flaws in the system. A Just Culture adds individual practitioner accountability to the concept of safety in an organization’s culture.

In a Just Culture, system design issues are balanced with individual accountability in evaluating a clinical error. It shifts the focus from that of errors and outcomes to one of system design and behavioral choices. This can be a huge culture change from that of blame and punishment that is sometimes found in a correctional setting. When health care staff have a real fear of being escorted out of the building for a clinical error, reporting near-miss and clinical mistakes is severely hampered.

High Reliability System Design

High reliability is critical in any system with increased likelihood of catastrophic events. High reliability system design first emerged in the nuclear power and air traffic control industries, where error can result in the significant loss of life. Since the emergence of data on the high number of deaths in health care related to clinical error, these design principles are increasingly applied in the clinical setting with positive result. High reliability design establishes system defenses to avoid human error. Safeguards and barriers within the care delivery system are a primary means of error prevention.

Re-engineering clinical processes using high reliability principles involves seeking system changes that reduce human error. Concepts of high reliability design include

• Mindfulness of potential error
• Formal structures and procedures that incorporate redundancy checks
• Informal culture open to safety accountability at all levels of the organization

Common tools used in high reliability systems include

• Buffers to detect error before it reaches the patient
• Reminders to help avoid reliance on memory
• Forced functions such as requiring specific actions before allowing movement to a next process step
• Process constraints that prevent a clinician from taking a risky action

Health care systems are complex adaptive systems where the communication among the parts is as important as the parts themselves. This is particularly true in a correctional setting where there is an added layer of communication with security officers, custody administration and, in jail settings, the police as well. The interaction of multiple decision-makers increases the need for a high reliability system design.

Communication and Teamwork

Effective communication and teamwork in the correctional setting must overcome barriers imposed by security requirements. Here are some examples of additional communication efforts needed in this setting.

• Health care staff may need to negotiate timing or location of care delivery with security officers, adding an additional layer of collaborative work.
• When the goals of health care and security conflict, tension builds, resulting in communication breakdown.
• Organizational structure can create communication silos that hinder safe patient care. Staff on off-shifts may need to communicate about patients with covering providers who are not familiar with the patient or the correctional environment.
• Many diagnostics and treatments must be accomplished outside the security perimeter. Communication with laboratories, diagnostic centers and specialty services can falter without well-established communication systems and astute, accountable practitioners.

Patient-Centered Care

A patient-centered approach to care can reduce the effect of the fragmented care delivery system inherent in the correctional environment. A patient focus – rather than an organizational or caregiver focus – shifts care-delivery priorities toward decreasing patient harm. The Institutes of Medicine (IOM) defines patient-centered care as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions”. This is a tall order in the correctional environment, where individualized attention may conflict with a system that values anonymity and no-one is allowed to receive specialized service or care. Yet, the patient is a key component of safety in the complex health care system: an active and informed patient provides additional safeguards and redundancy in care delivery. For example, patients can help with the prevention and early detection of potential error.

Competent Care Providers

Correctional health systems are challenged to provide the time and finances to adequately orient newly-hired staff and maintain the competence of incumbent staff. Staff development activities are rarely handled by dedicated staff educators and more likely considered a part of a unit manager’s responsibilities along with financial, staffing, and clinical responsibilities.

New staff may be unfamiliar with the unique nature of the secure environment and the inmate population. They must quickly learn to negotiate both the health care and the custody hierarchies to safely accomplish care. The autonomous nature of delivering health care in correctional environments requires staff members to fully understand the limits of their licensure and job descriptions.

Strict boundaries, identified in a traditional health care setting by policies, procedures, and organizational accountability structures, may be missing in the correctional setting. The uninformed health care professional can easily be swayed into inappropriate action by assuming that “it must be safe” if the request was made by a person of authority in the organization.

These five principles of patient safety provide a foundation for improving clinical processes and outcomes. They are a good starting point for evaluating current risk and developing a framework to reduce patient harm in a correctional health care setting.

What are your thoughts on these principles? How do you see them practiced in your setting?

Originally published in the Summer 2015 issue of CorrectCare™, the quarterly magazine of the National Commission on Correctional Health Care.