Healthcare Safety: The Big Picture

November, 2019

Abraham Maslow’s famous hierarchy of needs puts safety nearly at the base of the pyramid, just above basic physiologic needs such as food, sleep, and shelter. That’s because when a person faces real or perceived threats to safety, the desire to find safety will dominate behavioral motivation.

In healthcare, safety is equally foundational. Patients and families want to be safe when they seek care, and care team members need a safe environment in which to work. But even if safety is foundational, it’s not simple.

Physical Safety

Usually when we talk about safety, we’re talking about being safe from physical harm.

For patients and families, physical safety means following protocols to prevent sepsis and other hospital-acquired infections. It means eliminating Never Events and preventing even minor falls or other injuries that put patient well-being at risk.

New technologies such as algorithms that monitor vital sign data to detect infection earlier, and nurse call systems that speed up response times for toileting requests can help mitigate these risks.

For care team members, physical safety is more complicated. It includes having the right tools and protocols to eliminate unintended harm, such as needle sticks and lifting injuries. It also means protection from physical assault, which usually stems from patients who are aggressive and/or mentally compromised. Wearable “panic buttons” that accelerate security response to unsafe situations are often the best solution for these hard-to-predict events.

Psychological and Emotional Safety

Physical safety is critical, but psychological and emotional safety are equally important. The ability to show up without fear of disrespect or unfair treatment creates a deeper sense of security for patients and care team members alike.

For Patients and Families

For patients and families, emotional safety comes from feeling respected, cared for, and like they are in good hands.

At its deepest level, emotional safety for patients and families stems from an environment of equity and inclusion. It is strengthened by clear, empathetic communication. Leaders at Beth Israel Deaconess Medical Center in Boston have pioneered a process for capturing and categorizing emotional harm through their core safety management system so they can conduct root-cause analysis and decrease emotional safety incidents.

And emotional safety necessitates systems and protocols that enable team members to respond quickly and effectively to patients’ needs – especially for things such as pain management, toileting, nutrition, and other basics that patients can’t manage independently.

For Team Members

For team members, psychological safety can be defined as “being able to show and employ one's self without fear of negative consequences of self-image, status, or career ^i.” As with patients and families, this is based in a foundation of respect, equity, and inclusion. And there’s a profound ripple effect. When team members feel safe to speak up, voice concerns, and contribute without reprisal, they form the foundation of a culture of safety and continuous improvement.

Many healthcare organizations have put in place structures to encourage psychological safety through Just Culture, High Reliability, or similar programs. But most are finding they still have deeper work to do to uncover and undo the effects of implicit and even explicit bias that undermine psychological safety for team members.

Team members also face “moral injury” when they are not able to care for patients the way they feel patients deserve, due to demands stemming from non-care-related activity such as billing, legal documentation, or bureaucracy.

A Safe, Healing Environment

Physical and psychological safety are deeply interconnected. We know that physical harm has psychological repercussions. Likewise, we are beginning to understand the physical ramifications of psychological harm.

In the simplest terms, not being able to keep patients free from harm creates emotional burden on team members that can contribute to feeling and acting unsafe at work. Team members who work in an environment where they feel physically and psychologically safe can connect and communicate with empathy and respect, and focus their attention on safety processes and protocols.

Any comprehensive safety program must address both the physical and emotional aspects of safety. It’s not a band on a triangle of hierarchy. It’s a circle that’s self-reinforcing.

ⁱKahn, William A. (1990-12-01). "Psychological Conditions of Personal Engagement and Disengagement at Work". Academy of Management Journal. 33 (4): 692–724. doi:10.2307/256287