Insights From the Armstrong Institute What a Real Preoccupation With Failure Could Look Like Peter J. Pronovost, MD, PhD; Lori Paine, DrPH, MS, RN; Eileen M. Kasda, DrPH, MHS; Melinda D. Sawyer, DrPH, MSN, RN T he Joint Commission is guiding health sys- tems toward becoming high-reliability organiza- tions (HRO), similar to oil and gas, naval aviation, and nuclear power industries. These industries perform with a remarkable degree of safety, despite working in dynamic and hazardous conditions. This degree of safety performance is no accident. Two researchers studied HROs and found repeatable practices that helped ensure safety. 1 These organiza- tions function under 2 sociocultural conditions. Orga- nization leaders profoundly respect all employees, and all employees want to learn and improve safety and operations. They also operationalize 2 logics: (1) an- ticipate mistakes because all systems are fallible and standardize work when feasible to prevent mistakes and (2) recover from mistakes, building resiliency into daily work. HROs know they must manage error effectively, or they will spend all their time responding to errors. Thus, they create mindful organizing structures in which they constantly envision what could go wrong and design systems to defend against and recover from mishaps. Although this preoccupation with failure is a tenet of HRO, it is often overlooked in health care. Health care workers often assume things will go right rather than wrong. This is understandable because clin- icians choose health care to help people—to fulfill a sense of altruism. Such optimism that all is well poses significant risk to patient safety. To defend against risk, regulatory organizations such as The Joint Commission require that health care organizations conduct a proac- tive risk assessment at least every 18 months after a new or changing process. Although well intended, an 18-month stretch for risk assessments is hardly a preoccupation with failure. Pre- occupation with failure is a mindset, a way to mindfully organize work, applied by all staff every day on the job. Being mindful does not mean thinking longer or harder, Author Affiliations: Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland (Drs Pronovost, Paine, and Sawyer); School of Medicine, Johns Hopkins University, Baltimore, Maryland (Drs Pronovost and Sawyer); and The Johns Hopkins Hospital, Baltimore, Maryland (Drs Paine and Kasda). Correspondence: Peter J. Pronovost, MD, PhD, Johns Hopkins Medicine, Armstrong Institute for Patient Safety and Quality, 600 N. Wolfe St, CMSC 131, Baltimore, MD 21287 (ppronovo@jhmi.edu). The authors declare no conflicts of interest. Q Manage Health Care Vol. 26, No. 3, pp. 171–172 Copyright C  2017 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/QMH.0000000000000139 it involves thinking about and seeing risks and behav- ing to improve safety. The same sense of altruism can move every level of a health care organization to prac- tice this preoccupation with failure every day—make it a habit. 2 FRONTLINE CLINICIANS Clinicians can incorporate risk assessments into daily processes of care, such as patient rounds or care transitions. Ask the simple questions: How might this patient suffer harm and how can we defend against those risks? For example, a patient with swallowing difficulties may be at risk for aspiration and could be placed on aspiration precautions. When transferring care, whether to another unit or on discharge to a skilled nursing facility or home care, the sending care team can communicate their knowledge of the patient’s risks to the receiving care team. By incorporating a risk assess- ment into the handoff, information can be shared be- tween the sending and receiving care teams that will ensure all patient care needs are met. In daily care, clinicians should approach tasks with a mindset to look for errors rather than assuming what is in front of them is correct. For example, when nurses conduct a high-risk intravenous medication dou- ble check, the second nurse should assume the first nurse made a mistake, hunt for it, and correct it, rather than assume the intravenous pump is working or pro- grammed properly and the medication is right. By en- gaging in this mindset, clinicians can develop a preoc- cupation with failure. Frontline caregivers can also perceive near misses as equally important in the scheme of event reporting. Look for system defects that could cause harm and report them before an adverse event occurs. UNIT-LEVEL MANAGERS Unit managers can conduct huddles or briefings one or more times during the day to discuss clinical or oper- ational risks to patients. For example, a charge nurse and unit attending might discuss which patients they are most worried about, how they will manage the de- mand for beds, and what may happen in the evening when nurse staffing is reduced. Managers can also ask frontline staff that thought- provoking question, how will the next patient be harmed, and use their responses to proactively iden- tify and mitigate those risks. This question is asked in many units throughout our health system that use Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. July–September 2017  Volume 26  Number 3 www.qmhcjournal.com 171