Our quarterly newsletter covers one patient safety dimension in-depth in each issue. View previous issues.
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You may also discuss or comment using our online discussion forum.Welcome to the fourth issue of Patient Safety Tools, IPRO's electronic newsletter designed to provide information and resources on patient safety to health care providers across New York State.
We have adopted this format to increase the reach and effectiveness of our efforts to communicate a range of useful, current information regarding patient safety initiatives sponsored by IPRO and others. We hope that by bringing key findings, lessons learned, workable strategies, and practical tools to your attention, these newsletters will highlight proven ways to apply quality improvement processes to achieve transformational advances in patient safety.
In each newsletter, we are presenting information focused around one of the twelve safety dimensions for hospitals defined by the Agency for Healthcare Research and Quality (AHRQ) as implemented in their Patient Safety Climate Survey. This is a valuable survey that is currently being used by IPRO in a CMS directed rural hospital initiative to promote an improved hospital patient safety environment and is available for any hospital to use. The survey identifies specific patient safety strengths and vulnerabilities associated with each of the twelve measured dimensions and can facilitate a data-driven plan to engage senior leadership to promote safety improvement activities using specific evidence-based, proven interventions.
The patient safety dimensions that reflect various hospital processes are the following:
The first issue focused on using the SBAR technique to improve communication during the many handoffs and transitions that occur during any hospital stay. The second issue highlighted the absolute need for active and visible participation by hospital senior leadership, especially the CEO, in driving safety culture change efforts and provided tools that will permit busy executives to do so. The third issue examined how the prevailing and toxic environment of blame in hospitals prevents understanding how errors occur within systems. We provided thoughts, techniques, and resources that permit establishing a "just culture" in which organizational learning can take place. In this issue we will consider the necessity for more effective error reporting systems (including a better understanding and definition of "error"); the benefits of transparency and honest communication; and, the power of open disclosure and forgiveness in a just culture. We will also look at the existing "cultural" barriers to achieving these objectives and ways to overcome them.
In response to requests from hospitals interested in comparing their results against those from other hospitals on the Hospital Survey on Patient Safety Culture, the Agency for Healthcare Research and Quality (AHRQ) established the Hospital Survey on Patient Safety Culture Comparative Database. In spring and summer 2006, U.S. hospitals that administered the AHRQ patient safety culture survey voluntarily submitted their data for inclusion in this new database. The 2007 database consists of data from 382 participating hospitals and 108,621 hospital staff respondents who completed the survey.
The AHRQ asked hospital staff how many event reports they had filled out and submitted within the last 12 months - about 50% of the respondents answered none. Given that nothing is absolute, it is impossible for staff in direct contact with patients on a daily basis to have not seen any events in a 12-month period.
Although we may individually know what we see, we don't always discuss or report it. It has been shown that in hospitals where a higher number of people report mistakes, errors and near misses, it generally equates to a higher level of staff awareness of safety issues and a greater level of comfort with reporting. i,ii Ideally, 100% of staff should be aware of events that might cause or do harm to patients and feel comfortable with reporting these events.
Chief among the many reasons for our lack of comfort with reporting is our difficulty in acknowledging our own mistakes. We prefer to think that the problem of unsafe care rests with someone else, not ourselves. Here's why:
A 2007 Quality of Care Survey iii conducted by the American College of Physician Executives identified nine common obstacles to providing high-quality and safe patient care. See table below.
Note that 77% of respondents identified fear of reporting as an obstacle to patient safety; 87% identified a desire to maintain the status quo, and; an astonishing 93% identified patient compliance and habits.
In short, we do not report enough because it's in the culture not to report! And this is why we must devise workable ways with which to measure and improve hospital safety culture.
Before we discuss becoming more comfortable with reporting, let's explore what constitutes an error.
According to HcPro, a Healthcare Compliance Company, there are five types of errors:
As we become more familiar in identifying errors we need to devise strategies to promote reporting of errors. Here's a workable three-step strategy:
In order for us to begin to understand how errors can occur, we must adopt systems approaches, move beyond a culture of blame, and build partnerships that set aside conventional thinking among stakeholders. iv Furthermore - and probably most importantly - is our willingness to investigate how we, ourselves may have played a part in a breakdown or failure. In his article Behind Human Error: Human Factors Research to Improve Patient Safety, David Woods states, "...the process of investing in safety begins with each of us being willing to question our beliefs to learn surprising things about how we can contribute to the potential for failure in a changing and limited resource world."
Health care organizations need to plan for unexpected events, debate unintended consequences and design straightforward, uncomplicated systems to help staff understand and learn from all types of errors - from the seemingly benign to catastrophic events.
Learning activities should be presented in an environment of uninhibited communication and provide information on past failures and how they should be used to prevent similar events from occurring in the future. Moreover, along with activities that promote discussion of past events, staff should be taught how to proactively anticipate future harmful events. Certainly, it is important to note that because of the dynamic nature of the environments in which we work, protocol for error recognition and prevention should be updated regularly.
Given the freedom to discuss all types of errors and consider ways to prevent unwanted situations, fears of blame and repercussion will eventually diminish. With systems for error education firmly in place, a new pattern of thought and a more comfortable environment will emerge thus allowing people to come forward with their own ideas and share viable suggestions for improvement with their colleagues.
Click here to read David Wood's article in its entirety.Traditionally, hospital and healthcare safety has focused on identifying, counting, reporting, investigating, and resolving errors - also called incidents or adverse events. This process has identified human error as the primary root cause 85% of the time and personnel actions (retraining, censure, or dismissal) or reengineering as the solution. This is fine as far as it goes - but we all now know it doesn't go far enough! The end result of this approach has been to limit us to a very narrow range of options that address only a small piece of the safety puzzle and inhibit our ability to learn how to improve safety.
Human error plays a part, but research has shown that human error in hospitals occurs within complex systems of care in which there are multiple contributors to any failure. Pointing the finger at human error solely will not help us achieve the level of safety and quality we seek. The New Look at Error, Safety, and Failure: A Primer for Health Care & Primer Graphics and From Counting Failures to Anticipating Risks: Possible Futures for Patient Safety - both articles by David Woods and Richard Cook - articulate a way of thinking about error that seems a much better fit.
There is a unspoken social order in most hospitals which states that only physicians can report about physicians, nurses about nurses and so on - leaving all of the rest of the professionals, technical and allied health staffs, who can identify errors and potential problems out of the reporting mainstream. Vital information is not brought forward because a potential identifier of error is not from the same social stratum. We need to invite all who can contribute to identifying problems to be part of the process.
Timothy Hoff's brief commentary on his research, experience and thoughts on establishing a safety culture is worth taking to heart.v He contends that safety culture change efforts that focus on large-scale organizational change are impractical. He presents a brief, solid case for focusing "on using the everyday behaviors people are comfortable with, strategically aiming to get them to do little things that, when added together over time, produce the desired effects of enhanced attention to safety. In the end, we might produce more of the desired change because there is less resistance and fear from workers that their everyday worlds will be turned upside down." His focus on understanding the existing realities of day-to-day care delivery and his approach to creating new behaviors within existing work flow merits your consideration.
Click here to access.Traditional hospital event reporting systems are relatively insensitive to reporting patient safety incidents, especially those that cause harm.vi Many studies have documented that both doctors and nurses are reluctant to report incidents at all and that reporting frequency varies with the kind of incident, e.g. patient falls may be reported more frequently than pressure sores.vii,viii,ix Perceived barriers to reporting are many, including lack of feedback, cumbersome forms, insufficient time to report, and fear. Even more recent electronic reporting systems that encourage confidential reporting of an expanded list of events (medical errors, adverse events and near misses) demonstrate wide variations in the reporting rates among hospitals, and particularly low reporting rates by physicians.x
Current external event reporting systems - such as those mandated by some state health departments, the Joint Commission's Sentinel Event program, the United States Pharmacopeia and the Institute for Safe Medication Practices MedMARx system-are "...limited to certain types of errors and adverse events, and may not collect reports on near misses, and/or may not be familiar or accessible to all hospital employees."
So how do we go about creating an environment and reporting system? An informative place to start is to look at what the VA system has been doing.
Dr. James Bagian and others began applying aviation safety techniques and systems to the problem of medical and healthcare errors. With an emphasis on teamwork, standardization of procedures, culture change, and a requirement to report incidents through a confidential computerized system, the VA's, Getting At Patient Safety (GAPS) Center and the National Patient Safety Center (NPSC) provided rich resources and direction to understanding how we can all get comfortable with event reporting.
The patient safety movement has clearly identified the value of communicating, unanticipated outcomes of care, or errors in care delivery, with patients and family members. There remain, however, many gaps in knowing how to communicate this kind of information effectively and a reluctance to do soxi,xii
Why aren't we in healthcare more open when things go wrong?
In addition to those reasons already stated, we've been advised not to admit error by lawyers and risk managers-in part, because we may not know how. Lucian Leape, in a National Patient Safety Foundation (NPSF) Newsletterxiii makes a concise and cogent case for the need to talk openly and honestly when things go wrong.
"Its time for doctors and nurses to do what they have known all along is the right thing to do: tell the patient everything that happened, including how things went wrong, and express our genuine feelings of sorrow and remorse. We owe them, and ourselves, nothing less."
The Sorry Works! Coalition - an organization of doctors, lawyers, insurers, and patient advocates - was formed in 2005 for the explicit purpose of promoting full disclosure and apologies for medical errors.xiv Their web site houses a wealth of materials and resources for understanding the importance and value of disclosure as well as how to accomplish this successfully. The coalition advocates a six-step response to medical errors. Once the basic facts are known, providers should quickly move to:
A video produced by our sister QIO in Georgia provides a good introduction to thinking about what to say, how to say it, and who should do the talking. Several vignettes demonstrate what to do and what not to do. This may help you and your colleagues understand how to best approach crucial conversations about error.
The 55-minute video consists of two parts. Part One features a panel discussion of three clinical vignettes involving medical error. The panel is comprised of a medical ethicist, John Banja, a hospital risk manager, Susan Nemchik, and two healthcare attorneys, Temple Sellers and Jack Schroder. Part Two of the tape presents a host of empathic communication techniques that can be useful to health professionals when they conduct "bad news" conversations. Their scenarios demonstrate in a practical way the importance of the right person communicating unanticipated outcomes quickly, completely, respectfully, and apologetically. They also emphasize the need to recognize and gear the conversation to the health literacy level of patients and family members. Click here to access.
Finally, Johns Hopkins Hospital has articulated a straightforward philosophy and policy regarding medical error reporting disclosure which was presented by Albert Wu, MD and Sorrel King at the third annual Maryland Patient Safety Conference in March 2007xv and may be helpful in your thinking as you move forward. Please click here to view their handouts and read a summary of the policy.
Those of you who are talking about planning or are currently establishing a new plan for patient safety in your workplace need to be mindful that the process you are going through will be lengthy and difficult. Over the unintended harm we experience today and the planned perfection of tomorrow looms a shadow of culture, habit, and human behavior. However, merely thinking differently about error is an important and constructive first step. With changed thought processes in place, designing systems that permit individuals and organizations to learn from mistakes and prevent harm to patients will surely follow.
Our goal was to shed light on an all-too-important subject - that may have been shrouded by fear, discomfort and a lack of communication - but which needs to be discussed openly and given the utmost attention if we are to continue to ameliorate patient safety techniques. We hope that you have gained some new insights on this potentially controversial subject and will use it to further your own personal growth and that of your working environment.
Richard Corcoran, Safety Project Lead, rcorcoran@nyqio.sdps.org
Charles Stimler, MD, MPH, Medical Officer, cstimler@nyqio.sdps.org
Marguerite Shaffer, RN, Senior Director, mshaffer@nyqio.sdps.org
Patient Safety Tools is produced by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 8SOW-NY-TSK1C1-07-01.