True Patient Safety Begins at the Top

Physician Executive, Sept, 2001 by James P. White, Susan D. Ketring

Leaders at one large health system rally around safety, avoid blame game

IN THIS ARTICLE...

Making patient safety the No. 1 priority at a hospital or clinic sounds like a easy task. It isn't. At one Oklahoma health system, an improved patient safety program is a massive effort requiring input and participation from every member of the staff. Figuring out how to convince employees that patient safety is their first priority means developing an extensive communication and education program.

MEDICAL ERRORS CARRY high costs-both human and financial.

In human terms, consider not only the suffering for patients and their families but also the impact on health care workers who often get the brunt of blame.

The financial costs are significant. The November 1999 report from the Institute of Medicine (TOM) estimates that medical errors cost the nation approximately $37.6 billion each year.[1] About $17 billion of those costs are linked to preventable errors.

While the IOM report was criticized and its numbers disputed by another recent study, health care organizations still must strive to provide care to patients in the safest manner possible. Since long before the recent public attention, quality of care and patient safety were high priorities in most hospitals, particularly those accredited by the Joint Commission on Accreditation of Healthcare Organizations.

Historical efforts typically included:

* Fall prevention.

* Improvement in medication processes.

* Operative site identification.

* Prevention of hospital-acquired infection.

* Investigation of near misses.

INTEGRIS Health in Oklahoma is working to identify and coordinate expanded patient safety efforts and to sharpen its focus on this large and nebulous subject. To help simplify the complex issue, INTEGRIS developed "A Framework for Approaching Patient Safety."[2]

The framework opens with a vision of:

* Committing to patient safety at all levels.

* Engaging all employees in ensuring the safety of every patient.

* Achieving zero defects in clinical care.

* Becoming a high reliability organization that's preoccupied with the possibility of failure.

* Being perceived as the community leader in patient safety.

According to the experts, leadership is an essential ingredient of success in the search for safety.[3] So our first step in establishing a culture of safety is to be sure that leadership and the entire organization understand the rationale for a focus on patient safety.

Leaders must understand why errors are so difficult to reduce-that health care errors occur as a function of flawed systems, not individuals, and that health care systems are increasingly complex.[4]

This complexity of modern medical care is a major risk factor in medical errors, according to patient safety guru Lucian Leape. "We perform many interventions during hospital care. Each of them presents many opportunities for error. Indeed, the wonder is that there are not many more injuries," Leape said. [5]

However, as Leape also notes, even an error rate nearing perfection can have serious consequences in a modern hospital.

Even if the medication ordering, dispensing, and administration system were 99.9 percent error free, in a hospital the size of INTEGRIS Baptist Medical Center, there might still be almost 5,000 errors a year. If only 1 percent of those result in a serious adverse event, 45 to 50 patients might be harmed. [5]

It's your fault

The reliability of our health care delivery system rests on people, [6] but unfortunately, systems that rely on perfect performance by individuals to prevent errors are doomed to fail. The reason is simple: all humans, even our best and brightest and even our most experienced, make mistakes.

Physicians and other hospital leaders must understand that only when human mistakes are accepted as inevitable will it be possible to shift away from a punitive frame of mind and focus on identifying underlying systems failures. [7]

The traditional approach of fixing blame, imposing discipline, retraining, and writing new policies will not prevent human error. It will stifle discussion and discovery of the causes of error.

Instead, we need involvement at the grassroots level. We need our staffs to speak freely, to talk about errors that happen and those that almost happen. We need them to identify where mistakes are likely and where our systems allow mistakes to get through. They can help us learn where we need to focus our attention.

We have used several models of error to illustrate these issues for leadership, including modified "Blunt End/Sharp End" models and the "Swiss Cheese" model:

In the Blunt End/Sharp End Model, hospitals and their policies, procedures and systems are in the blunt end of this large object pointed at the patient.

Practitioners--physicians and nurses in particular--are at the sharp end, affected by resources and constraints. Most of the time they use their knowledge, training, attention and skill to directly interact with the patient, who benefits from correct diagnoses, tests and treatment decisions and skilled surgeries. Healing occurs.