Three Steps to Improve, Learn and Heal After a Harm Event

June 9, 2021

A 70-year-old woman was hospitalized following surgery to repair a broken ankle due to a fall at home. On her first day postoperatively, she fell again while in her hospital room. During the investigation of the hospital fall, it was identified that members of the nursing team involved in her care were inconsistently using the fall risk assessment tool and not committing to the implementation of interventions to reduce her risk of falling. The hospital used the lessons learned from this investigation to assemble a process improvement team who developed a revised patient fall program. The hospital then shared the harm event story when it rolled out the program hospital-wide to demonstrate the need for the revised fall program and to challenge complacency among the care team about reducing falls.

Moving forward after a harm event involves implementing best practices to mitigate potential future risk and sharing lessons learned across the organization.

While each harm event may be unique on the surface, there are common fundamental steps that can help organizations improve, learn and heal.

Step One: Execute action plans to mitigate future risk

Step one begins where the investigation and analysis of a harm event leaves off, executing the action plans to mitigate similar future risk. Give team members involved in the harm event the opportunity to be part of the process improvement project team. To ensure the plan’s success, it’s important to obtain an executive-level sponsor(s). Create a timeline and commit to a goal date for completion to keep the improvement project on track. Consider using proven process improvement methods such as PDSA (Plan, Do, Study, Act) cycles to test care process changes.

Step Two: Share lessons learned across the organization

Step two involves sharing lessons learned across the organization.

“Use storytelling to help leaders and care team members internalize the lessons learned in a meaningful way, these are often called safety stories.”

Monica Chadwick, Senior Risk Consultant at Constellation®

Storytelling ensures the patient’s voice is heard and helps humanize the event. Identify lessons from completed investigations and cause analysis reviews to share across the organization to avoid future similar situations. Protect confidentiality by removing identifiable components from the story including the individual harmed or the individual care team members involved. Be sure to share both positive and negative insights discovered during the investigation, as well as actions taken in response to the harm event.

Step Three: Reinforce a learning culture and safety in reporting

Sustainability happens when an organization can take the lessons learned after a harm event and spread that knowledge across the entire organization. Use lessons learned as opportunities to encourage team members to speak up when they recognize unsafe practices, see policies not followed or have other concerns.

“Using safety stories reinforces the organization’s commitment to  safety and to fostering a learning culture when reporting and responding to  harm events.”

Heather Meyer, Senior Risk Consultant at Constellation

The keys to sustainability include:

  • Reflecting a culture of accountability  for reporting of errors and near misses through non-retaliation statements in policies and in leadership practices.
  • Celebrating when reporting leads to process improvement, increased near miss reporting and reduction of  harm events.
  • Seeking feedback from team members who have been involved in harm events about their experience, whether they felt safe and supported, or whether they felt mistakes were not used for learning and improving.
  • Utilizing metrics or a scorecard to demonstrate accountability for goals around early, open communication and learning.

Doing Better After a Harm Event: The HEAL® Prepare Toolkit

Our HEAL Prepare Toolkit helps your organization prepare for harm events so you can respond quickly and effectively. The Toolkit includes a unit on moving forward after a harm event that contains assessments, best practices, sample tools and coaching. Start your journey by taking the HEAL Assessment and then the Action Plan will guide you through the Toolkit’s four units: (1) culture, (2) event response, (3) patient communication, and (4) moving forward. Sign in to to access the HEAL Prepare Toolkit found in Risk Resources.

Constellation’s HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.


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