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The Time is Now: 'Culture of Safety' Key to Preventing Errors

Monday August 23, 2010
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When staff nurses at the University of California, San Francisco Medical Center recently attended a patient-safety class devoted to infection control, they listened to a mother whose child acquired a surgery-site staph infection while in the hospital for a biopsy. The mother talked about how some clinicians wouldn’t acknowledge that her child’s infection was caused by their care, how the child spent three weeks in the ICU, how many months later, the child and her family still dread driving by the hospital because of their terrible experience.

“For the nurses to hear that was very powerful” because it illustrated the harm clinicians can unknowingly do to patients when they don’t follow proper safety procedures, says Kathleen Burke, RN-BC, BSN, chair of the UCSF Patient Safety Fellows, a group of staff nurses devoted to patient-safety issues that puts on the “Stories From the Bedside” classes. Much of patient safety is about awareness, she says. “We’re not aware many errors are preventable. The general myth is still pervasive — that errors occur by negligent or uncaring health professionals, and of course that is not me.”

Culture of Safety
Ten years after the Institute of Medicine’s “To Err is Human” report concluded medical errors are mostly the fault of systems rather than individuals, patient-safety advocates, researchers, quality analysts and others are using scientific methods to determine why those systems continue to allow preventable medical errors to happen. What they are finding is although improvements in methods and technologies can be useful tools, the most important factors in improving patient safety remain the human ones — leadership, communication, teamwork, staff empowerment — which help create what patient-safety experts call “a culture of safety” with the patient at the center.

“Culture change is kind of the lubricant that allows patient-safety work to happen,” says Christine Goeschel, RN, MPA, MPS, ScD, director of patient safety and quality initiatives and manager of operations for the Johns Hopkins Quality and Safety Research Group at the Johns Hopkins School of Medicine in Baltimore, and founding executive director of the Michigan Health and Hospital Association Keystone Center, a patient-safety improvement group.

Preventable mistakes still kill about 100,000 people a year, according to consumer groups, despite national attention given to the issue since the IOM report attributed 98,000 U.S. deaths annually to preventable medical errors. Some believe the slight increase may be the result of better reporting, and the number of errors actually may have decreased somewhat. But most patient-safety experts say the healthcare industry has done a poor job of reducing preventable medical errors in hospitals and nursing homes.

“It probably is better reporting, but the public deserves better than that,” says Peter Pronovost, MD, PhD, medical director of the Center for Innovation in Quality Patient Care at the Johns Hopkins University School of Medicine, and author of “Safe Patients Smart Hospitals, How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out,” about his work with checklists and safety culture at Johns Hopkins and hospitals in Michigan. “We can send a ship to Mars. We can sequence the entire human genome with 99.9% accuracy. Surely we can reduce [preventable] errors.”

Evidence-Based Tools
Some progress has been made. By studying other industries such as aviation, research in the relatively new science of healthcare delivery has produced a number of evidence-based tools, including checklists for preventing infections, “time-outs” before a surgery and “no interruption zones” for nurses giving medications. New technologies include computerized physician-order entry systems, bar codes for patient and medication identification, safe pumps, electronic health records and computerized prompt systems.

Some studies show extraordinary results for these tools. Using a five-step checklist developed by Pronovost, ICUs in Michigan virtually eliminated central-line catheter infections and have continued to keep infection rates at near zero three years after the procedure first was adopted. The use of a surgical safety checklist developed by the World Health Organization decreased deaths and major postoperative complications by 36% in eight hospitals around the world, according to a New England Journal of Medicine study published last year. A recent study out of Brigham and Women’s Hospital in Boston found that a combination of bar-code technology and electronic medication administration records substantially reduced medication errors and essentially eliminated transcription errors.

Researchers for these projects say the new procedures and technologies work only when accompanied by efforts to improve the safety culture of the hospital, the involvement of the healthcare team and the collection of data to show clinicians the tools actually work. In Michigan, along with the checklist, Goeschel, Pronovost and their colleagues introduced the Comprehensive Unit-Based Safety Program, which included improving communication among clinicians; improving teamwork; engaging leadership; focusing on surveillance, monitoring and feedback; and using a patient-safety culture assessment. They are working to expand the project nationally.

The culture piece is often the most difficult part, Goeschel says. “If it was as easy as adapting the checklist, our work would be done.” Data collection and feedback are also important, she says. “Once clinicians begin to see success, it’s empowering and it feeds on itself.”

Before introducing bar codes, researchers at Brigham and Women’s studied workflow patterns to see how the technology could best help nurses give medications safely, says Carol Keohane, RN, BSN, program director for the Center for Patient Safety Research and Practice at Brigham and Women’s, and a co-author of the bar-code study. They tested the technology for potential barriers to adoption, finding nurses preferred the full screens of regular-size laptops to tablet computers. Researchers and nurse educators explained bar codes were an extra safety net to verify medication administration, not a replacement for nursing expertise or critical thinking.

But the greatest buy-in from nurses comes when the bar code prevents a potential error, Keohane says. “When you scan and get an alert and say, ‘I could have made a mistake,’ you’re a convert.”

Patient Advocacy
Linda Flynn, RN, PhD, FAAN, associate dean of graduate education at Rutgers College of Nursing in New Jersey, is project director and principal investigator for the Medication Safety Initiative, a study funded by the Interdisciplinary Nursing Quality Research Initiative. In a survey of New Jersey nurses in 14 hospitals, she found nurses reduced medication errors when they asked physicians to rewrite an order that didn’t use standard wording or was unclear; questioned why a patient was receiving a particular medication; did their own medication reconciliation; and educated patients and families about medications they were receiving.

The likelihood of nurses doing these things, she says, “was predicted by the work environment,” and specifically five factors: strong frontline nursing leadership; good collaboration between physicians and nurses; adequate resources; participation in decision-making; and foundations for quality, such as good mentoring, orientation and in-service education.

Pronovost and other patient-safety researchers have found that clinician empowerment is an extremely important pillar in creating a strong safety culture. Error reports from state health departments are full of examples of nurses who saw physicians make errors or skip procedures and didn’t say anything because they felt intimidated. “Nurses are blessed because they see themselves as patient advocates,” Pronovost says, and in most cases they are. “But for some reason they don’t always advocate for adhering to safety standards.” They may rightly fear a physician will snap at them, or throw something, or even get them fired, he says.

Nurses who clearly understand a patient’s safety takes precedence over a physician’s wrath or the need to complete a task in a given time will feel more empowered to speak up or take time to complete safety protocols, patient-safety experts say. “The first thing nurses can do is fully focus on the patient,” says Ann Blouin, RN, PhD, executive vice president in the division of accreditation and certification operations at The Joint Commission. “If they do that, a lot of cultural stuff falls by the wayside.”

Instead of adopting an accusatory or pleading tone, nurses remind physicians and other teammates that they understand everyone is working together for the good of the patient, and that to provide safe care, proper procedures must always be followed.
If a colleague does not respond after two respectful requests or reminders, nurses need to go up the chain of command, Blouin says. But this works only when management is supportive. In a 2007 workforce study of New Jersey nurses, Flynn found 42% of RNs said their manager would not back them up when they were in conflict with a physician.

“The unit-based nurse manager is key,” she says. But many are not ready to intervene in a dispute with a physician or do not understand their roles in guaranteeing patient safety, often because they don’t feel backed up by their own supervisors. “I think we have a long way to go in terms of preparing frontline nurse managers,” Flynn says.

Even in hospitals with strong safety cultures, preventable mistakes still happen. Then it’s time to re-examine and possibly fine-tune the procedures in a transparent way, says Charlotte Guglielmi, RN, BSN, MA, CNOR, president of the Association of periOperative Registered Nurses, and a perioperative nurse specialist at the Beth Israel Deaconess Medical Center in Boston.

Learning Culture
Beth Israel is an early user of patient-safety technology and innovations and has a strong culture of safety, Guglielmi says. But two years ago, an experienced surgeon there operated on the wrong side of a patient. Instead of hiding the error, the hospital’s CEO, Paul Levy — a longtime patient-safety advocate — sent an e-mail disclosing it to hospital staff. Investigators discovered, among other things, that even though the surgical team had used a checklist, not all team members were sure of their roles. The hospital’s surgical checklist now reads like a script, designating which person reads out — and is responsible for — each part. Any team member who has concerns with the way the time-out is done can stop the procedure.

“We need to be involved in the solution,” Guglielmi says. “A culture of safety is a learning culture.”

The best learning comes when people are not afraid to talk about mistakes, Burke says.

In the four-hour “Stories from the Bedside” classes, offered four times a year, UCSF nurses present case studies of patient-safety errors and near-misses that have occurred on their units — often the nurse involved in the error is the one presenting the story. The idea is for nurses to learn that what has happened to colleagues easily could happen to them, Burke says.

Although there are many things individual nurses can do to keep their patients safe, real changes most likely will come from the top, driven by patients and payers, patient-safety advocates say. As healthcare consumers become more aware of patient-safety issues and preventable medical errors, and as payers such as the Centers for Medicare and Medicaid Services increasingly say they will deny payment for treatment required because of a preventable error, hospitals will have no choice but to make patient safety paramount. The day may come, Burke says, when hospital administrators will tell even their most brilliant clinicians up front, “If you want to work here, you need to wash your hands.”

Cathryn Domrose is a staff writer.

To comment, e-mail editorNTL@gannetthg.com.
Checklist for Nurse Patient-Safety Advocates

Nurse patient-safety experts offer these suggestions for nurses who want to work to reduce medical errors:

1. Embrace double-check systems. Whether it’s technology (smart pumps and bar codes), a checklist, or asking another nurse to be an extra set of eyes, patient-safety experts recommend nurses have some way to double-check their work. Though all of these systems take a few minutes more and experienced nurses may feel they are unnecessary, they do catch errors, studies have shown.

2. Engage patients and families in their own care. Some hospitals are doing shift handoffs in front of the patient and encouraging patients and family members to speak up if something doesn’t seem right, such as if a patient has allergies to a certain medication. Nurses also should advise patients and family members to always ask providers — including the nurse — to wash their hands in front of them, to ask surgeons to mark where their surgery will be, and to ask for an explanation of any part of their care they don’t understand.

3. Speak up when patient safety is at stake — if a surgeon skips part of a time-out, if you don’t understand why a patient is receiving a certain medication, if a clinician forgets to wash hands. Rather than accuse or hint, be factual and specific, using evidence and facility policy to back up your concern. Make your concern known immediately, and be prepared to go to a supervisor if a colleague does not respond after two reminders or requests.

4. Report errors and near-misses. Reporting is an important first step to correcting the systems that create them. This is much easier in a hospital with a strong culture of safety. If your facility is not one of those, try to make your voice heard as best you can by letting administrators know that you would like it to be one, and remind them that as payers and patients become more savvy about medical errors, a hospital that can document fewer errors will eventually deliver more cost-effective care.

5. Create a personal culture of safety by encouraging members of your healthcare team — including nursing assistants, technicians and housekeepers — to inform you if they notice anything amiss, be it a patient who is walking more slowly to the bathroom or that you forgot a certain procedure. Let all members of your team know that the ultimate goal of the team is to create a safe environment for the patient, and that you will not treat their concerns defensively or dismissively.

6. Work with leadership whenever possible, letting administrators know nurses want to help them to create a culture of safety. Form or sit on safety committees, bring safety studies to leaders’ attention, work with technology committees to let nurses’ needs be known, work with your nursing association to develop safety guidelines and best practices. Rather than work around a reoccurring problem, gather colleagues and supervisors to discuss what can be changed to fix it.

7. Stay up-to-date on patient safety issues and your facility’s safety policies. The Joint Commission’s Journal of Patient Safety and its website; the National Patient Safety Foundation; the Agency for Healthcare Research and Quality’s Quality and Patient Safety website; statewide patient safety coalitions; and the Empowered Patient’s Coalition are all good resources for new patient safety research and practices. Use this information to work for change at your own facility.

8. Mentor new nurses on the importance of patient safety. Empower them to use patient-safety tools and techniques, stay current on safety research, speak up when they see something is not right, and report errors and near-misses. Also, listen to new grads who may be more up-to-date on the latest patient safety research, and encourage them to share their knowledge.

9. Don’t give up. Patient safety advocates say protecting patient safety is daunting work, particularly for nurses who don’t feel backed up by administrators or colleagues. Find like-minded colleagues — nurses, physicians, administrators — to work with you. “We can’t wait for big system changes to come. We have to start now,” says Kathleen Burke, RN-BC, BSN, chair of the UCSF Patient Safety Fellows, a group of staff nurses devoted to patient safety issues. “We are the last line of defense for our patients.”