Table 2

Summary of key interventions comprising the Caring Safely programme and associated high-reliability organisation principles

InterventionDetailsAssociated high-reliability organisation principles
Board training in safety40 41 Two-day training offered by the collaborative twice yearly. Content included: epidemiology of harm in hospitals, safety culture, interpretation of data and strategies for effective safety governance.Board training promotes the principles of preoccupation with failure and sensitivity to operations by equipping those responsible for governance with an understanding of foundational concepts necessary to recognise threats to safety and the status of organisational safety and reliability, and the ability to interpret and respond to safety events and harm data.
Leadership Methods training1 8 36 40–45 One 2-hour training for all managers, directors and senior leaders. Content included: methods for leader rounding (to observe frontline practice and to influence staff regarding the importance of safety efforts), giving effective feedback, prioritising safety issues and enabling just culture. An organisation-wide Daily Safety Brief intervention was taught and implemented as part of the Leadership Methods training.The set of practices taught in this training foster the principles of preoccupation with failure, sensitivity to operations and commitment to resilience by encouraging direct observation and interaction with frontline work and creating structures and processes that establish situational awareness for the purposes of anticipation and real-time problem-solving and learning.
Error Prevention training40 42 44 45 One 3-hour interactive workshop for all staff. Content included: overview of harm in healthcare, how safety events occur, and tools for effective teamwork and communication behaviours. Tools include: Introduction by Name and Role, Assertion Tool, Mindfulness Tool, Verification and Resolution Tools, Tool for Escalating Information, Closed-loop communication and Handoff Tool.The set of individual and team practices taught in this training support the principles of preoccupation with failure and sensitivity to operations (eg, identifying small anomalies and practising mindfulness when conducting safety critical or error-prone tasks), reluctance to simplify interpretations (eg, maintaining critical thinking and a questioning attitude to promote verification of information) and deference to expertise (eg, explicit use of tools that facilitate communication of information or assertion of concern across hierarchical levels and professional boundaries).
Safety Coach programme36 44–46 One 2-hour training and ongoing meetings to develop volunteer peer coaches. Content included: a review of Error Prevention (expected safety behaviours and tools) and strategies for giving effective feedback. Safety coaches were expected to act as a coach in the course of regular work, by giving immediate positive feedback when safety behaviours were observed, reviewing safety behaviours, and accompanying tools, or pointing out missed opportunities to act safely or use the tools. Documentation of coaching encounters, including date, area, safety behaviour and coaching type, via a REDCap survey, was encouraged to track coaching activity centrally.The Safety Coach programme reinforces the same principles as Error Prevention training (above), by equipping volunteer coaches with skills for making behaviours explicit and giving positive feedback when the skills are successfully used, or for providing coaching when opportunities to use the tools have been missed.
Cause Analysis36 40–42 Complete overhaul of safety event classification and analysis system. Five staff attended a 2-day training on the Serious Safety Event Classification system.47 A formal Root Cause Analysis system that entails individual interviews with all involved staff, formal classification of all proximal and root causes, and a three-meeting model for event review leadership to include objective peers in establishing causal mechanisms and corrective actions.This Cause Analysis model promotes the principles of reluctance to simplify interpretations by using individual interviews with all staff involved in an event and by introducing objective peers into the steps in which causal mechanisms are articulated and existing assumptions and practice questioned. The focus on all staff participating and having input on corrective action also reflect commitment to resilience and deference to expertise.
Healthcare-acquired conditions (HACs)*36 42 Prevention bundles48 targeting each HAC as recommended by the safety collaborative.The programmes related to the implementation of HAC bundles relied on principles of reluctance to simplify interpretations, sensitivity to operations and deference to expertise in that senior leaders used rounding to learn from frontline staff about gaps in knowledge and practice, so that educational programming and auditing systems could be designed to achieve highly reliable performance of bundle practices.
Serious Patient and Employee Safety EventsMultimodal continuous improvement: culture and leadership interventions described above in addition to continuous improvement resulting from Cause Analysis.The Leadership Methods, Error Prevention and Safety Coach programmes all aim to prevent these events and thus support the principles as listed above. In addition, the system created to respond to harm events fosters commitment to resilience by establishing structures and processes around accountability for implementation of corrective actions and collective learning from events.
  • *Caring Safely HACs include (1) central line-associated bloodstream infection, (2) surgical site infection, (3) pressure injury, (4) catheter-associated urinary tract infection, (5) fall resulting in serious harm, (6) peripheral intravenous catheter injury and (7) unplanned extubation.