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Since the seminal report by the Institute of Medicine, To Err Is Human, was issued in 1999, significant efforts across the health care industry have been launched to improve the safety and quality of patient care. Recent advances in the safety of health care delivery have included commitment to creating high-reliability organizations (HROs) to enhance existing quality improvement activities. This article will explore key elements of the HRO concept of deference to expertise, describe the structural elements that support nurses and other personnel in speaking up, and provide examples of practical, evidence-based tools to help organizations support and encourage all members of the health care team to speak up.
Keywords: deference to expertise (DTE); patient safety; Magnet; TeamSTEPPS
Recent advances in the safety of health care delivery have included questioning how traditional, authoritarian cultures may contribute to medical errors and suboptimal care. This article will highlight how deferring to expertise rather than authority can promote a safer and more effective health care delivery system.
BACKGROUND
In 1999, the Institute of Medicine (IOM) released the report, To Err is Human, which permanently altered the way we think about quality and safety in health care. Prior to this report, most clinicians assumed that some level of harm, and even death, were just a rare and unfortunate byproduct of medical interventions. The report estimated that up to 98,000 hospital deaths per year resulted from medical errors (IOM, 1999). More recent reports suggest that this number is likely closer to 400,000 deaths per year (James, 2013; Makary & Daniel, 2016), and, despite intensive efforts, there is limited success in improving safety for patients (Wachter, 2010).
Reducing harm to patients is a challenge in complex health care systems. Efforts to decrease harm include use of technology, financial disincentives, policy changes, public reporting of data, research funding for safety programs, and innumerable local safety initiatives (Wachter, 2010). There are increasing calls for organizations to become high-reliability organizations (HROs; Chassin & Loeb, 2013). HROs are known for minimal safety incidents despite complex and risky processes; the airline industry is commonly used as an exemplar for reliably safe processes. Several key components of HROs that are highly relevant to health care include preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment...