YNHHS leaders stress the importance of reporting, HRO behaviors and support in reducing errors

After the recent conviction of a former Nashville, TN, nurse for a medication error that led to a patient’s death, Yale New Haven leaders reassured staff that the health system is committed to being a high reliability organization (HRO), and has seen a marked reduction in patient safety events over the past 10 years.

“There’s been a lot of fear, a lot of conversation around ‘Could that be me?’” YNHHS Chief Nurse Executive Beth Beckman, DNSc, said of the Tennessee case during a March 31 town hall with employees.

She stressed that using HRO CHAMP safety behaviors will help staff keep themselves and their patients safe. Beckman was joined by leaders from Quality and Safety, Accreditation and Regulatory Affairs, Human Resources, Medical Staff, Nursing and other departments. 

The town hall was prompted by employees’ concerns about a March 25 jury verdict that found former Vanderbilt University Medical Center nurse RaDonda Vaught guilty of criminally negligent homicide and abuse of an impaired adult. In 2017, Vaught inadvertently injected a 75-year-old patient with a powerful paralyzer, vecuronium, when the patient was prescribed a sedative, midazolam (trade-named Versed). 

Yale New Haven leaders said that while they don’t know the circumstances of that case, YNHHS has worked hard to promote a “just culture.” That means the health system recognizes that nearly all patient safety events are the result of flaws in procedures, processes and systems, not just an individual’s behavior. Rather than blame people for errors, a high reliability organization with a just culture works to identify and fix the flaws to prevent future errors.

“We work hard to understand if there were any breakdowns in our safety systems and why those breakdowns were allowed to occur,” said Steven Choi, MD, YNHHS vice president and chief quality officer. “We support our healthcare workers and colleagues in creating an environment to keep our patients safe.” 

During the March 31 special town hall and the YNHHS town hall the day before, leaders encouraged employees to continue using HRO CHAMP behaviors and reporting safety events, including near-miss events, via the online RL Solutions tool (in network only). 

Thomas Balcezak, MD, YNHHS chief clinical officer, said that employees and physicians have been consistently reporting events for years – which has undoubtedly improved patient safety at YNHHS. 

“This means we are getting great information about where there is potential for something dangerous to happen, and we can take progressive action to prevent it,” he said. 

Event reporting is a crucial component of YNHHS’ HRO program, which has reduced episodes of patient harm by more than 80 percent since launching in 2014. Nevertheless, leaders acknowledged, human errors and systems failures do occur, due to the complex nature of the healthcare setting. 

“We recognize that health care is complex,” Dr. Balcezak said. “We encourage everyone to follow existing safety policies and practices and use HRO CHAMP behaviors to help prevent errors.”