A Culture of Safety – Hospitals Have Transformed the Way They Prevent Medical Errors

Almost two decades after its publication, the report still startles those who read it.

It’s called “To Err is Human,” and it was dropped on the healthcare world in 1999 by the Institute of Medicine (IOM). At its heart was the claim that at least 44,000 people — and perhaps as many as 98,000 — were dying in hospitals every year as a result of medical errors that could have been prevented.

Even using the lower estimate, those preventable medical errors in hospitals exceeded deaths from threats like motor-vehicle wrecks, breast cancer, and AIDS. The higher estimate was simply staggering. And unacceptable.

“That’s like a jumbo jet crashing every few hours — it was absolutely frightening that I could face these risks going to the hospital,” said Dr. Simon Ahtaridis, chief medical officer at Mercy Medical Center. “Suddenly, it was all hands on deck.”

However, he said, there was no conventional wisdom early on about exactly how to eliminate those fatalities.

“We knew we wanted to reduce errors, but we did not know how to do it,” he said. “And at times, maybe we were a little misguided, too punitive. What we needed to do was build a culture of safety.”

Indeed, for the first five years or so after the report, Ahtaridis continued, hospitals were being more aggressive about cracking down on errors and punishing those who made them, but not doing enough to root out the causes and focus on prevention. For many health systems, he said, the epiphany came with the realization that a safety culture couldn’t emanate from one administrative department; it had to be integrated into every corner of the system — and it had to gain front-line employees’ trust.

Among the common problems outlined in the IOM report were adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities.

Those are mistakes that cross over into myriad departments, and, indeed, the report put some of the blame on the decentralized and frag-mented nature of the healthcare delivery system. “When patients see multiple providers in different settings, none of whom has access to complete information, it becomes easier for things to go wrong,” it noted.

Linda Riley agrees. The manager of Infection Prevention at Cooley Dickinson Hospital (CDH) said boosting patient safety requires buy-in across departments, from materials management to quality control to IT to finance.

“It’s hospital-wide, and everyone has a piece of this,” Riley said. “Nothing happens in a silo anymore. We use data to move things forward, and work in teams that have specific goals and are measuring to see how they are meeting those goals.”

There’s no room for laxity anymore, Ahdaritis added. When someone hears, for example, that a medication order has a one in 100 error rate, they may think that sounds reasonable, but there could be dozens of steps from the time a drug is ordered and inputted into the computer until it reaches the bedside, and a 99{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} success rate on each of those steps isn’t anyone’s idea of patient safety. So, no, he added — a 1{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} error rate is not acceptable. Neither is 0.1{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}; the goal is zero. But how?

“We’re focused on decision-making rather than outcomes,” he said, noting that a surgeon might have gotten a pass in the past on a questionable decision that didn’t cause harm, whereas today the focus is on the process.

“The IOM report was a big wake-up call. While people always valued safety, it took time to realize that meant changing the way we acted and thought,” he told HCN. “Are you willing to implement reporting mechanisms, change your culture, provide education, have staffing necessary to address quality concerns? The budget crunch a decade ago might have affected the quality department, but today, that’s untouchable.”

Taking Responsibility

Across the industry, however, perhaps the most important key to cultivating a culture of safety was making sure entire organizations — from senior leadership to front-line staff — are comfortable communicating openly without fear of reprisal.

“If we have any errors in the provision of care, one piece is reporting,” said Avadhoot Gokhale, chief Quality officer at Holyoke Medical Center. “But the other piece is creating an environment where people are not afraid of reporting and making sure that, if we have an error, we look at it instead of brushing it under the rug. Let’s work on it and make sure this doesn’t happen again.”

Aiding that process is a safety committee that meets every morning to examine internal incident reports — what went well, what didn’t go well — but, more importantly, create an action plan to prevent the same mistake in the future.

“Even if we know why an error occurred, why mistakes are made, we need to do something about it — the buck stops here,” he said. “What’s important is that we’re taking action so it doesn’t happen again. My philosophy is, we’re human. We are not gods here. When you make a mistake, you own that mistake and make the necessary process changes so it doesn’t fail you again.”

That ‘it’ refers to the process itself, and by implying it was the process that failed, Gokhale was not taking any responsibility from the provider who made the mistake. Rather, that distinction is key to preventing future mishaps. It’s not enough to place blame; hospital quality-control leaders need to identify where in the process the mistake occurred and consider how that process can be tweaked so the next person who performs the same task is already statistically less likely to mess up.

Ahtaridis had similar thoughts on the balance between holding providers accountable and creating an unhelpfully punitive culture.

“Historically, if you stepped forward with a patient-safety concern, you were putting yourself at risk as a troublemaker. In the past decade and a half, they’ve become heroes,” he said. “We have an error-reporting system with the opportunity to report things anonymously, but most people add their name when they bring an issue forward, and they’re not reprimanded. That’s a tremendous change from before.”

While penalties for bad behavior are appropriate in some cases, he explained, the goal was to create a system that makes it hard for people to fail in the first place, and that requires a focus on what went wrong in the process, not necessarily who should be punished. “If we see that 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the staff is not following something, it’s a system problem. If one person’s decision was inappropriate, that’s a person problem, and needs some intervention.”

As part of that increased safety culture at Mercy, once a week, all senior leadership meet — in what Ahtaridis called a “sacred time,” with no meetings or phone calls allowed to intrude — and visit every area of the hospital to engage staff and talk about how things are going, particularly any safety concerns they might have encountered and concerns and barriers they’re encountering to doing their job.

Some fixes are simple, inexpensive, and surprising in how easy they are to implement. For example, one idea was issuing purple slippers to patients with a high fall risk; if a staff member sees them ambulatory on their own, they know to help them get back to bed. In another easy change, the techs that stock patient and procedure rooms with supplies used to have to visit three or four storage areas, and it was easy to forget something. Now, they have been given well-stocked, mobile carts and can turn over rooms quickly and more reliably.

Riley noted that, through changes in training and monitoring, Cooley Dickinson has been successful at reducing urinary-tract infections from catheters, which are historically among the most common infections in hospitals. Meanwhile, its efforts, begun more than a decade ago, to change the way it handled patients on ventilators have resulted in a total elimination of ventilator-associated pneumonia cases.

Other efforts to reduce infection at CDH include an electronic system that monitors whether doctors, nurses, and other care providers are cleaning their hands before seeing patients, and use of an ultraviolet disinfecting technology to clean patient rooms.

“A lot of work happens in meetings and in teams,” Riley said. “We use the data we collect from our medical records and surveys and observations people make on the units, and we prioritize problems we have and develop what we think are solutions, implement them and educate the staff, and then look at the data again to see if what we implemented actually makes sense for patients.”

In short, she added, “we are working very, very hard to ensure these infections don’t happen.”

Shine a Light

While area hospitals all say their efforts to reduce errors and infection rates predate the IOM report, they concede “To Err Is Human” was an industry-wide wakeup call, one that has spawned a cottage industry of patient-safety watchdogs, most notably the Leapfrog Group, which formed in 2000 and has honored many area hospitals — including all three participating in this story — with its Top Hospital honor in recent years.

“When you shed a light on infections, you know how many you have. And when you’re comparing yourself to other people, you want to do better,” Riley said. “Then there are the financial incentives; hospitals get rewarded for positive outcomes and penalized for negative outcomes.”

Ahtaridis also noted those financial considerations. “If we’re at fault for a hospital-acquired condition, that affects reimbursements. Some payers won’t pay for that — they’ll say, ‘you created that; that’s on you.’ Is it 100{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} fair? Maybe not, but it does change behavior.”

And that’s really what all these efforts come down to: making the hospital a safer place for patients, who expect providers to follow that key tenet of their oath, ‘first, do no harm.’

“When we do the right thing,” he told HCN, “we take care of patients, which is more important than anything else — the financials, the numbers, the metrics.”

And doing the right thing became easier once safety became a culture, not just a task.

“You have to make sure you have a non-threatening culture,” Gokhale concluded, “so everyone feels empowered to raise their hand and go to work fixing what’s wrong.”

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