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Chapter 42 – Patient Safety

Part 3 - Professional Services

Title Section
Introduction 3-42.1
        Purpose 3-42.1A
        Policy 3-42.1B
        Scope 3-42.1C
        Background 3-42.1D
        Authorities 3-42.1E
        Program Policy 3-42.1F
        Definitions 3-42.1G
Responsibilities 3-42.2
        Director, IHS 3-42.2A
        Headquarters Office of Quality, Division of Quality Assurance and Patient Safety 3-42.2B
        Area Director 3-42.2C
        Area Chief Medical Officer 3-42.2D
        Governing Body 3-42.2E
        Chief Executive Officers 3-42.2F
        Clinical Director 3-42.2G
        Director of Nursing 3-42.2H
        Director, Quality Assurance and Performance Improvement 3-42.2I
        Patient Safety Officer 3-42.2J
        Safety Officer 3-42.2K
        Risk Management Committee 3-42.2L
        The IHS Facility Department Supervisors 3-42.2M
        The IHS Employees 3-42.2N
Procedures and Core Elements of a Patient Safety Program 3-42.3
        General Program Requirements 3-42.3A
        Risk Assessment and Management 3-42.3B
        Tracking and Trending Data 3-42.3C
        Quality Improvement 3-42.3D
        Safety Culture 3-42.3E
        Training 3-42.3F
        Recognition of Excellence 3-42.3G
Manual Exhibits Description
Manual Exhibit 3-42-A, [PDF - 121 KB] “Patient Safety Policy Implementation and Maintenance Checklist”
Manual Exhibit 3-42-B, [PDF - 82 KB] “Optional Risk Assessment/Management Tools”
Manual Exhibit 3-42-C, [PDF - 80 KB] “Core Patient Safety Program Elements References”


  1. Purpose.   This chapter establishes the program policies, procedures, and responsibilities required to ensure that a comprehensive, systems-based, Patient Safety program exists in all Indian Health Service (IHS) health care facilities. This chapter will provide a road map for the IHS to achieve a health care environment where there are zero incidents of preventable harm to patients.
  2. Policy.   The IHS policy is that all health care facilities maintain a systematic, coordinated, and continuous approach to maintaining and improving patient safety through risk management evaluation. Implementation of this policy must include the establishment of mechanisms that support effective responses to actual occurrences; ongoing, proactive risk assessments to support reduction of risk that could result in patient safety hazards or occurrences; and integration of patient safety priorities into the new design and redesign of all relevant organizational processes, functions, and services. This Patient Safety policy outlines the components of the IHS Patient Safety program. As used in this policy, Total System Safety (TSS) refers to a unified approach to both patient and workforce safety. The TSS requires a shift from reactive, piecemeal interventions, to a proactive patient safety strategy that anticipates risks and establishes system wide safety processes that are applied across the entire health care continuum.
  3. Scope.   This chapter applies to IHS-operated health care programs and/or facilities, referred to in this policy as IHS facilities, (which includes, but is not limited to, hospitals, critical access hospitals, ambulatory care, and behavioral health treatment facilities), Area Offices, Headquarters (HQ), and employees. Tribally operated and Urban Indian Organization health care programs and/or facilities may adopt this policy. The content of this chapter is intended to augment other Indian Health Manual (IHM) chapters, circulars, special general memoranda, and policy in general. Related IHS policies include those on Event Reporting, Infection Prevention and Control, Occupational Safety and Health, as well as IHM Chapters from Part 3-Professional Services. The TSS recognizes the symbiotic relationship between patient and workforce safety, however, this chapter addresses patient safety only. Workforce safety is addressed in other IHM chapters, including the Occupational Safety and Health chapter. Intentionally unsafe acts (see 3-42.1.G(11)), and actions to be taken in response to intentionally unsafe acts, are not addressed in this chapter.
  4. Background.  
    1. The intention of the health care system is to support and promote the health and wellness of patients and not to cause harm during the course of care. The IHS is dedicated to providing high quality health care without causing harm to patients or staff during that care. It is imperative that IHS leaders and clinical staff have a clear picture of what is actually happening in their health care settings so that appropriate steps can be taken to prevent harm to patients and the workforce.
    2. The IHS has adopted a TSS Strategic Plan to achieve the aim of zero incidents of preventable harm and to improve outcomes. The IHS TSS outlines the IHS's patient safety strategy and acknowledges that in order to achieve the IHS’s aim:
      1. The IHS must understand the health care continuum as a system, and emphasize the IHS TSS improvement initiatives to identify and remediate system vulnerabilities that can result in patient and/or workforce harm.
      2. The IHS must encourage the reporting of system vulnerabilities as a mechanism through which the IHS can learn about those vulnerabilities and how to address them. As a system, the IHS cannot mitigate flaws and risks that the IHS does not know about. All staff will report adverse events, good catches (for a definition of this term, please see 3-42.1.G(6) in the definition section of this policy), and potential risks in the IHS adverse event reporting system (see also IHM Chapter 3-43, Event Reporting, Tracking, and Response).
      3. Proactive risk mitigation and implementing a just culture, while simultaneously holding everyone accountable for safe behaviors, is the foundation of the IHS safety culture. These program elements must be emphasized as crucial factors in identifying and mitigating system vulnerabilities that will lead to the reduction of adverse events.
    3. As an organization, the IHS recognizes that the health care system is extremely complex and that humans will make mistakes. The IHS must design and improve IHS systems with human factors in mind (make it easy to do the right thing and hard to do the wrong thing). The IHS must utilize the concepts of high reliability systems as tools in risk identification and mitigation.
    4. The IHS will use improvement science and quality improvement methods and tools to implement knowledge-based actions that can be formulated, tested, and implemented at the local, regional, and national levels to effectively mitigate system vulnerabilities that can lead to patient and/or workforce harm.
  5. Authorities.  
    1. Snyder Act, 25 U.S.C. § 13
    2. Indian Health Care Improvement Act, 25 U.S.C. § 1601 et seq., as amended
    3. Federal Tort Claims Act, 28 U.S.C. §§ 2671-2680
    4. Confidentiality of medical quality assurance records; qualified immunity for participants, 25 U.S.C. §1675

      Note: Records generated as part of the IHS Medical Quality Assurance Program are confidential per 25 U.S.C. §1675 and will be handled in accordance with 25 U.S.C §1675 and any other applicable authorities.
  6. Program Policy.   The IHS policy is that:
    1. Each IHS facility will establish a comprehensive Patient Safety program consistent with relevant patient safety Federal regulations and guidance, facility accreditation organization standards, scope and level of services provided, and evidence-based best practices.
    2. The leadership and management of the IHS at all levels of the organization will provide support in the form of staff, facilities, equipment, supplies, time, and training to establish and implement the Patient Safety program.
    3. Health care facilities will integrate their Patient Safety program into their Quality Assurance and Performance Improvement (QAPI) program or Quality Improvement (QI) program.
    4. This policy provides a basic minimum framework for an agency-wide Patient Safety program. Each IHS Area and all IHS facilities will ensure that their Patient Safety programs meet the minimum standards laid out in this policy.
    5. Policy compliance verification will be completed by HQ, Office of Quality (OQ) in collaboration with the Area Directors, or their delegated designee, (see 3-42.2.B(3) and 3-42.2.C(2)) according to mutually established guidelines. Manual Exhibit A, Patient Safety Policy Implementation and Maintenance Checklist, is a tool provided to assist with policy compliance verification.
  7. Definitions.  
    1. Accreditation.   Accreditation refers to the official review process that allows health care facilities to demonstrate their ability to meet standards set forth by the accrediting organization. Requirements differ per accreditation organization, however, being accredited means that a health care facility has met certain quality and safety standards. These standards are set by private, nationally recognized groups that evaluate the quality of care at health care facilities and organizations.
    2. Adverse Event or Adverse Incident.   An undesired outcome or occurrence, not expected within the normal course of care or treatment, disease process, condition of the patient, or delivery of services at the organization that involves death or harm. This definition also includes any process variation in which a recurrence of the event/incident carries a significant chance of an adverse outcome.
    3. Aggregated Reviews.   Aggregated reviews look at all adverse events and good catches (for a definition of this term, please see IHM 3-42.1G(6) in the definition section of this policy) in a particular event category during a specified period of time (e.g., all patient falls in the first quarter of the fiscal year). Aggregated reviews look at system trends and potential improvements.
    4. Comprehensive Systemic Analysis.   A comprehensive systemic analysis (CSA) is a process for identifying basic or causal factors underlying variation in performance, including the occurrence or possible occurrence of a sentinel event (for a definition of this term, please see 3-42.1.G(20) in the definition section of this policy).
      1. Root Cause Analysis.   A root cause analysis (RCA) is a specific type of CSA that is most commonly used for an adverse event or good catch requiring analysis. Consistent use of the RCA further refines the implementation and increases the quality and consistency of CSA. To avoid confusion, the term RCA is used to denote the CSA.
      2. Corrective Action Plan.   A corrective action plan (CAP) is the product of an RCA that identifies strategies that the organization plans to implement to reduce the risk of similar events occurring in the future. The plan will address staff assignment of responsibility for action implementation, oversight, pilot testing, if appropriate, timelines, and methods for measuring the effectiveness of the recommended actions. Corrective action plans will include follow-up intervals. Corrective actions will be specifically designed and appropriate to address the root causes identified.
    5. Event or Incident.   Any occurrence that is not consistent with the routine care or operation of the organization or its services.
    6. Good Catch.   Circumstances that have the capacity to cause an event or incident, whether or not it would have been adverse, but did not cause an event or incident either by chance recognition or through timely intervention. Good catches are opportunities for learning and afford the chance to develop preventive strategies and actions. Good catches are also referred to as close calls and near misses. Some example categories of good catches are:
      1. Hazardous conditions;
      2. Category A or B medication safety event/incident; and
      3. Patient safety interventions.
    7. Harm.   Temporary or permanent impairment of the physical, emotional, or psychological function or structure of the body and/or pain that requires intervention.
    8. Health Care Personnel.   Health care personnel (HCP) are employees, volunteers, students, trainees, and contract workers who have contact with patients.
    9. High Reliability Systems/High Reliability Organization.   High reliability systems/high reliability organization (HRO) are organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. Concepts utilized to achieve high reliability include:
      1. Preoccupation with Failure.   Everyone is aware of and thinking about the potential for failure. People understand that new threats emerge regularly from situations that no one imagined could occur, so all personnel actively think about what could go wrong and are alert to small signs of potential problems. The absence of errors or accidents leads not to complacency, but to a heightened sense of vigilance for the next possible failure. Good catches (near misses/ close calls) are viewed as opportunities to learn about systems issues and potential improvements, rather than as evidence of safety. People in HROs understand that the work is complex and dynamic. They seek underlying, rather than surface explanations.
      2. Reluctance to Simplify.   People resist simplifying their understanding of work processes and how and why things succeed or fail in their environment.
      3. Sensitivity to Operations.   Based on their understanding of operational complexity, people in HROs strive to maintain a high awareness of operational conditions. This sensitivity is often referred to as “big picture understanding” or “situational awareness.”
      4. Deference to Expertise.   People in HROs appreciate that the people closest to the work are the most knowledgeable about the work. Thus, people in HROs know that in a crisis or emergency, the person with the greatest knowledge of the situation might not be the person with the highest status or seniority. Deference to local and situational expertise results in a spirit of inquiry and de-emphasis on hierarchy in favor of learning as much as possible about potential safety threats. In an HRO, everyone is expected to share concerns with others and the organizational climate is such that all staff members are comfortable speaking up about potential safety problems.
      5. Commitment to Resilience.   A commitment to resilience is rooted in the fundamental understanding of the frequently unpredictable nature of system failures. People in HROs assume the system is at risk for failure, and they practice performing rapid assessments of, and responses to, challenging situations. Teams cultivate situational assessment and monitoring, so they may identify potential safety threats quickly, and either respond before safety problems cause harm, or mitigate the seriousness of the safety event. (Agency of Health Care Research and Quality (AHRQ), September 2019).
    10. Human Factors.   A human-centered science that discovers and applies information about human behavior, abilities, limitations, and other characteristics to the design of tools, machines, systems, tasks, jobs, and environments for productive, safe, comfortable, and effective human use.
    11. Intentionally Unsafe Acts.   Intentionally unsafe acts, as they pertain to patients, are any events caused by staff actions including, but not limited to, the following:
      1. A criminal act;
      2. Reckless behavior and/or at-risk behavior;
      3. An act related to alcohol or substance abuse by an impaired provider and/or staff; and
      4. Events involving alleged or suspected patient abuse of any kind.
      Intentionally unsafe acts must be addressed through avenues other than those defined in this policy.
    12. Just Culture.   A just culture recognizes that individual staff must not be held accountable for system failings over which they have no control. The organization and its leadership are accountable for the systems they have designed and for supporting the safe choices of both management and staff. Each employee is accountable for the choices and behaviors they make within the organization. Each employee consistently reports events, good catches, and risks for potential errors or harm. It requires a shift of focus from errors and outcomes, to system design and management of the behavioral choices of all employees to strengthen processes and systems that result in an increase in patient safety.
    13. Lateral Violence.   A deliberate and harmful behavior demonstrated in the workplace by one employee to another.
    14. Patient Safety.   Patient safety is ensuring freedom from unexpected or inadvertent injury of patients, both physical and psychological.
    15. Proactive Risk Assessment.   Proactive risk assessment is a method of evaluating a product or process to identify system vulnerabilities and their associated corrective actions, before an adverse event occurs.
    16. Quality Improvement.   Quality improvement is the framework used to systematically improve care. Quality improvement seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, health care systems, and organizations.
    17. Quality Improvement Methods/Tools.   Stand-alone strategies or processes that can help staff better understand, analyze, or communicate QI efforts. Examples include run charts; control (Shewhart) charts; process maps; driver diagrams; fishbone diagrams; the model for improvement; Plan, Do, Study, Act tools; QI charter documents, etc.
    18. Risk Management.   Risk management is a complex set of clinical and administrative systems, processes, and reporting structures designed to help staff detect, monitor, assess, mitigate, and prevent risks to patients.
    19. Science of Improvement.   The science of improvement is “an applied science that emphasizes innovation, rapid cycle testing in the field, and spread in order to generate learning about what changes, in which contexts, produce improvements.” It is characterized by the combination of expert subject matter knowledge with improvement methods and tools. It is multidisciplinary – drawing on clinical science, systems theory, psychology, statistics, and other fields.
    20. Sentinel Event.   Sentinel events are a type of adverse event defined as an unexpected occurrence involving death, serious physical or psychological injury, or risk thereof. Serious injury specifically includes loss of limb or function. The phrase “risk thereof,” includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome(s).
    21. Total Systems Safety Strategy.   A proactive patient safety strategy in which risks are anticipated and system wide safety processes are established and applied across the entire health care continuum. The goal of TSS is to constantly improve systems and processes leading to a learning organization that administers highly reliable, quality care. These systems provide a unified approach to both patient and workforce safety in recognition of the importance of workforce safety, and that a safe workforce contributes to a safer patient care environment.


  1. Director, IHS.   The Director, IHS, or their delegated designee, is responsible for:
    1. The administrative issuance of this policy; and
    2. Ensuring this policy is fully implemented throughout the Agency
    3. .
  2. Headquarters, OQ, Division of Quality Assurance and Patient Safety.   The HQ OQ Division of Quality Assurance and Patient Safety is responsible for:
    1. Developing and facilitating the IHS-wide Patient Safety policies, standards, initiatives, and procedures;
    2. Consulting with the IHS Areas, IHS facilities, and IHS National Combined Councils in the development of performance measures and quality improvement projects;
    3. Ensuring compliance with this chapter according to the IHS guidelines;
    4. Developing internal controls to validate policy compliance;
    5. Recommending resources to train and educate Patient Safety Officers (PSO), specifically, and the IHS employees more broadly;
    6. Recommending patient safety resources and tools;
    7. Responding to inquiries from frontline HCP about the interpretation of patient safety guidelines, accreditation, and compliance standards, National Patient Safety Goals, or other requirements; and
    8. Consulting with the Area IHS Offices and the IHS facilities in response to Patient Safety trends, high-risk Patient Safety events, and high-risk patient-safety related accreditation findings.
  3. Area Director.   The Area Director, or their delegated designee, is responsible for:
    1. Ensuring this policy is fully implemented in their respective Area; and
    2. Providing HQ OQ verification of policy compliance upon request.
  4. Area Chief Medical Officer.   The Area Chief Medical Officer, or their designee, is responsible for:
    1. Providing patient safety technical consultation for the Area;
    2. Serving as the patient safety consultant and advisor to the Area Director and Area Program Staff on all matters related to patient safety; and
    3. Monitoring IHS facilities in the Area for compliance with this chapter.
  5. Governing Body.   The Governing Body is responsible for:
    1. Ensuring compliance and accountability with these standards and this chapter;
    2. Dedicating a portion of every Governing Body meeting to a review of pertinent patient safety data and analyses;
    3. Follow-up of patient safety data, RCAs, and CAPs, as appropriate; and
    4. Requiring members of the Board maintain the basic patient safety knowledge and training required to implement their oversight responsibilities.
  6. Chief Executive Officer.   The Chief Executive Officer (CEO) is responsible for:
    1. Elevating patient and workforce safety as a top priority within the organization;
    2. Requiring a just culture and a safety culture;
    3. Supporting the development and implementation of an ongoing prospective risk assessment process for the safety of patients, visitors, and staff, which includes patient safety as a primary component;
    4. Ensuring that issues identified by the Patient Safety program are addressed through the QAPI and training programs;
    5. Empowering and supporting the authority of staff managing the Patient Safety program to ensure effectiveness of the program;
    6. Review, concurrence, and implementation follow-up of all CAPs for issues identified as requiring improvement; and
    7. Ensuring staff with specific Patient Safety service or oversight responsibilities have adequate training and resources to implement a comprehensive Patient Safety program.
  7. Clinical Director.   The IHS facility Clinical Director, or a designated physician, is responsible for providing technical assistance to the PSO and supporting the implementation of the Patient Safety program.
  8. Director of Nursing.   The IHS facility Director of Nursing, or equivalent, is responsible for providing technical assistance to the PSO and supporting the implementation of the Patient Safety program.
  9. Director, Quality Assurance and Performance Improvement.   The QAPI Director, or equivalent, is responsible for overseeing the implementation of the Patient Safety program and providing management, budgetary, and logistical support as appropriate to the local organizational structure.
  10. Patient Safety Officer.   The PSO is responsible for implementing the day-to-day activities of the Patient Safety program consistent with facility accreditation standards, Federal regulations, best practices, and IHS policy.
  11. Safety Officer.   The safety officer (SO) is responsible for implementing the day to-day activities of the Environment of Care program consistent with facility accreditation standards, Federal regulations, best practices, and IHS policy. This generally includes workforce safety, environmental safety, and non-clinical patient safety.
  12. Risk Management Committee.   The multi-disciplinary facility Risk Management Committee, or its equivalent, is responsible for supporting the PSO, CEO, and the facility related to patient safety. The Risk Management Committee is responsible for:
    1. Assessing risks, making decisions and recommendations, and communicating requirements to staff throughout the facility/Service Unit;
    2. Evaluating the effectiveness of the local Patient Safety program;
    3. Analyzing patient safety data for potential trends; and
    4. Monitoring compliance and practice to ensure the goals and objectives of the program are met.
  13. The IHS Facility Department Supervisors.   Individual department supervisors are responsible for:
    1. Implementing this Patient Safety policy in their department;
    2. Ensuring employee compliance with safe work practices;
    3. Supporting patient safety education and training of their staff; and
    4. Participating in routine and periodic inspections of their work environment with a patient safety focus.
  14. The IHS Employees.   All IHS employees are responsible for:
    1. Complying with this policy and all subsequent local policies related to patient safety;
    2. Identifying potential patient safety issues and taking immediate action, as appropriate to their professional scope, to prevent or correct such issues;
    3. Reporting all identified adverse patient safety events, good catches, and risks to patient and workforce safety in the IHS online adverse event reporting system; and
    4. Participating in the development, implementation, and evaluation of the Patient Safety program.


  1. General Program Requirements.  
    1. Organizational Placement.   Each IHS facility will integrate the Patient Safety program into the QAPI/QI program. Patient Safety staff will be members of the facility Risk Management Committee, Safety Committee or facility-specific equivalent. Patient safety staff includes the PSO and other relevant Patient Safety staff.
    2. Resource Allocation.   Leadership of each IHS facility must ensure that sufficient fiscal and human resources are available to implement the Patient Safety program. Each facility will maintain up-to-date copies of all pertinent professional standards, guidelines, and regulations as outlined in the HQ Area, or local policy and as appropriate to their services and equipment.
    3. Recommended Staffing Levels.   Each IHS facility will designate at least one staff member to oversee and implement the Patient Safety program; i.e., the Patient Safety Officer. The designated staff member can be dedicated staff working under a patient safety position description, or they can be a dual-hatted staff member with explicit delegated authority over the patient safety program signed by the IHS facility CEO or their designee.
    4. Patient Safety Officer Competencies.   Patient safety officers will be qualified through education, training, experience, or certification. The PSO and his/her/their supervisor will regularly develop short- and long-term goals for individual development. The PSO will maintain their qualifications through ongoing education and training, participation in Patient Safety courses, and/or in local and national meetings organized by recognized professional organizations and Federal agencies, such as the Agency for Healthcare Research and Quality (AHRQ). The PSO and their supervisor will maintain documentation of current competencies.
  2. Risk Assessment and Management.   Risk assessment and management are central components of all Patient Safety programs. The subsequent items listed below are tools for the assessment and management of patient safety risks that will be used by all IHS Patient Safety programs in accordance with this policy. Manual Exhibit 3-42-B, “Optional Risk Assessment-Management Tools,” lists additional, optional risk assessment/management tools.
    1. Adverse Event Reporting.   All IHS staff will adhere to the policies set forth in the IHM 3-43, Event Reporting, Tracking, and Response Policy.
    2. Root Causes Analysis.   All IHS facilities will refer to the IHS Event Reporting, Tracking, and Response Policy for information about events and good catches that require the completion of an RCA. All RCAs will be conducted using the IHS standardized methodology, tools, and documentation. These procedural items are located on the IHS Adverse Event Reporting Training website and the Office of Quality, Patient Safety website. If a facility does not have an event or a good catch that meets mandatory RCA criteria in a 12-month period, staff will conduct an RCA tabletop training exercise in order to maintain RCA proficiency. The RCA scenarios can be provided by the Area Office, through HQ, or can be made available online or on demand, and may include de-identified scenarios from other IHS facilities or health systems that required an RCA.

      The end product of all RCAs will be a CAP as defined in this policy. The RCA CAPs will identify strategies that the organization plans to implement to reduce the risk of similar events occurring in the future. The plan will address staff members designated as responsible for action implementation, oversight, pilot testing (if appropriate), timelines, and methods for measuring the effectiveness of the recommended actions. Action plans will include follow-up intervals.
    3. Aggregated Review.   Facilities will conduct an aggregated review when negative patient safety events with similar root cause(s) are identified (i.e., an increase in patient falls, surgical site infections, sterilization issues, etc.)
    4. Proactive Risk Assessment.   Facilities will conduct a minimum number of proactive risk assessments of high-risk processes annually as prescribed by their accrediting body.
  3. Tracking and Trending Data.   All IHS facilities will track and trend patient safety data. Patient Safety data and analysis will be provided to facility leadership and the Governing Body by the PSO, quality manager, or designee at Governing Body meetings.

    The IHS Adverse Events Reporting System Patient Safety Dashboard, which is maintained by HQ OQ, is one resource that provides Service Units with facility-level patient safety data. All facilities have access to the IHS Adverse Event Reporting System Patient Safety Dashboard via facility log-in users. Other data sources are listed in this policy.
  4. Quality Improvement.   All facilities will use data to drive QI initiatives that strengthen processes and systems, increase patient safety, and improve outcomes. All IHS facilities will complete at least one QI project annually that directly addresses patient safety. Quality improvement projects that directly address patient safety can overlap with other topics or departments. Examples include, but are not limited to, infection prevention, implementing risk identification tools, such as the AHRQ Surveys on Patient Safety Culture or risk identification trigger tools, projects aimed at decreasing preventable negative patient outcomes, such as falls, pressure ulcers, hospital acquired infections, etc.
  5. Safety Culture.   All leaders in the IHS will employ methods to promote a safety culture. The items listed below are examples of ways to promote a safety culture. Items that are mandatory are indicated within the subsection. The other listed examples are optional.
    1. Just Culture.   All leaders will create a system of shared accountability in which:
      1. The organization and its leadership are accountable for the systems they have designed and for supporting the safe choices of both management and staff.
      2. Each employee is accountable for the choices and behaviors they make within the organization.
      3. Each employee consistently reports events, good catches, and risks for potential errors or harm.
    2. Modeling Behavior.   The act of modeling behavior that strengthens the safety culture. This can include the IHS leaders sharing mistakes they have made in the past, acknowledging that humans will make mistakes, and focusing attention on strengthening systems to mitigate or eliminate human error. The IHS leaders will treat others with respect and in a civil manner, and will not tolerate rudeness, incivility, lateral violence (for a definition of this term, please see 3-42.1.G(13) in the definition section of this policy), or bullying of any kind within the organization.
    3. Closed Loop Communication.   The act of providing follow-up communication to staff who report good catches, adverse events, and risks. This communication will be as widespread as needed and can include communication with teams, units, departments, or the entire facility. Communication will include information on the risk identified and how future risk will be mitigated. Closed loop communication enforces the importance of event reporting. It communicates to staff that the time spent reporting an event, good catch, or risk was not in vain and has contributed to strengthening systems and increasing patient safety. This kind of communication will be undertaken in accordance with Federal privacy laws and otherwise refrain from providing specific details, such as identifying staff or patients involved in an event whenever possible.

      Staff who submit good catch and adverse event reports that result in an RCA must receive feedback on the actions being taken as a result of their report. The feedback will be timely in nature and come from the PSO, or other appropriately designated party. Prompt feedback to staff reporting adverse events has been credited in other reporting systems with being one of the cornerstones that establishes trust in the system. It demonstrates organizational seriousness and commitment to the importance of the reporting effort. Staff who report need to be made aware that reporting an adverse event, good catch, or potential risk is not a waste of their time.
    4. Methods to Increase Good Catch and Adverse Event Reporting.   Leadership must adopt strategies to encourage and advocate staff identification and reporting of adverse events and good catches. Leaders and patient safety training will emphasize the value of good catches in identifying needed system redesigns. Identification and reporting of adverse events and good catches, including those that appear to result from practitioner error, need to be part of routine practice. Patient safety training will reinforce an understanding that events often characterized as human error are commonly due to systems problems. Training will emphasize that even the most conscientious, knowledgeable, and competent professional can make mistakes and that the goal is to understand these events to prevent them from causing harm to patients.
  6. Training.  
    1. Initial training.   All staff will receive initial patient safety training within 30 days of hire. Training will include adverse event reporting and orientation to this policy and the IHM 3-43, Event Reporting, Tracking, and Response Policy.
    2. Annual training.   All staff will receive annual patient safety training.
  7. Recognition of Excellence.   Recognizing staff for their efforts to improve patient safety through risk identification, adverse event and good catch reporting, and quality improvement reinforces the importance of those activities in keeping patients safe. All levels of the health care system will integrate patient safety into their recognition of excellence programs.