One day after the wedding, my colleague’s new husband was in the yard chopping wood when his foot slipped and he fell, landing with his full weight on his back. My colleague took him to the emergency room, where luckily the injured newlywed was seen quickly; it was a slow night. As treatment began for what turned out to be a broken scapula, the nurse failed to wash his hands or put on gloves before he prepped to start an IV. Recognizing the potential safety issue, my colleague nicely but firmly insisted that the nurse don some gloves before the needle went in. No unnecessary harm done.
What if my colleague had not been there to observe this nurse’s transgression?
Her injured husband was in significant pain. He wouldn’t have noticed the lack of hand hygiene if she hadn’t, and that might have resulted in an infection. Even the smartest and most observant people lose their ability to think rationally when they are in distress.
This is why patient safety must continue to be at the highest level of importance in our healthcare system. Since 1999 when the Institute of Medicine dropped its bomb and estimated that as many as 98,000 people were dying in hospitals from preventable medical errors each year, healthcare leaders have sought to identify solutions and implement quality and safety improvement programs. Despite these efforts, however, fifteen years after that report, analysis by the Institute for Healthcare Improvement (IHI) indicated there is still a long way to go.
Even more troubling, a 2016 analysis article in the BMJ estimated the number of preventable deaths at more than 250,000 per year, which would make preventable patient harm the third leading cause of death in the U.S. A main reason for the higher number, the article explains, is that “medical error” is not included on death certificates or in rankings of cause of death.
Regardless of which of these numbers is correct, Houston, we still have a problem. Consider these questions as you work toward eliminating preventable errors and harm.
1. Does your organization have safety initiatives, or a culture of safety?
Implementing a bunch of quality and safety initiatives may seem like progress, but it won’t significantly change the number of lives saved over time. It’s admirable to reduce central line-associated bloodstream infections in the ICU by 80%. But it’s not enough.
To achieve bodacious safety goals, an organization must create a culture of safety. And given the complexity of most health systems, as well as revolving leadership and changing reimbursement systems, that ain’t easy. But without complete cultural assimilation of things such as no blame, better communication, and strong, consistent leadership, organizations will continue to miss the mark.
2. Are you learning from failure or failing to learn?
When a plane crashes, the NTSB conducts an investigation, writes a report, and posts it into a public, online database for the industry to access and learn from. When a medical malpractice suit is settled, it typically comes with a gag order.
You can’t learn from failure if you don’t have 100% of the organization’s errors and near misses to evaluate. You can’t learn from errors unless the lessons learned and system modifications are disseminated and teams are educated about how to do things differently. Organizations that are truly prioritizing the importance of safety walk their talk when it comes to transparency and continuously learning. Some healthcare organizations have moved toward these goals, but many have not. If yours is in the latter group, the IHI white paper, A Framework for Safe, Reliable, and Effective Care, offers a robust roadmap.
3. Are you really involving patients and families or just giving lip service to “engagement?”
We’ve done a pretty good job with surgical checklists, protocols, and programs. But a not so good one integrating the patient. Okay, so maybe we “engage” them through a survey. Give them better food choice and delivery options. Offer access to electronic health record (EHR) portals.
But the trajectory toward a culture of safety must include patients and families in the design phase, not just in the feedback loop. We’ve got to share not only the gold star moments, but all the warts and skeletons too. Given the wide variability in education, socio-economics, and age of most hospital patient populations, the process is admittedly difficult. But the insights gained will be significant.
4. What are you doing to celebrate and communicate success?
I’m not talking about putting your STARS or HEDIS rating on a billboard. I’m talking about truly infiltrating a culture of safety mindset throughout the organization and across the community.
Do people really know what you are doing to keep them safer, or why they should care? How thoroughly have you integrated this message into patient, family, and beneficiary communications? How do you recognize and reward what your teams are doing to make things better for patients? In what ways do you move beyond metrics to humanize safety and quality?
Organizations with an unwavering focus on safety celebrate culture shifts, quality heroes, and system changes that save lives.
 Medical errors - the third leading cause of death in the U.S., BMJ 2016;353:i2139