Your Patient Safety Survival Guide
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For example, while serving as a cochair of the National Patient Safety Forum, which vetted safety-related products, Denham successfully lobbied the organization to unjustly and unfairly recommend a specific product for preventing bloodstream infections—a product that only CareFusion produced. Denham’s path to becoming editor of the Journal of Patient Safety turned out to involve undue pressure and unprecedented actions that are inconsistent with academic standards. Under his editorial watch, Denham authored and published papers in the journal that had clear and undisclosed conflicts of interest.
Until the Denham scandal broke, the field of patient safety had rested on its laurels, assuming that everyone was a do-gooder with pure intentions. With hindsight, it was painfully obvious that there were plenty of red flags about Denham’s motives, as well as his sudden rise to prominence and tendency to lavish compliments and support toward the movement’s prominent projects and people.32, 33 The Denham scandal marked the end of innocence for the movement. Like other areas of the healthcare industry, the patient safety movement had to come to terms with the reality that billions of dollars rest on which policies, practices, and products flourish and which ones die.
A Paradigm Shift—Zeroing In for Success
In 2010, my work began focusing primarily on helping industrial and manufacturing companies improve the safety culture in their organizations; however, I kept watching what was happening in healthcare—something that was possible, in part, because Leah Binder and David Classen, along with other colleagues of his, graciously invited me to attend annual conferences hosted by The Leapfrog Group and Pascal Metrics. Watching things unfold, it occurred to me that, as I described in an article published in Society, a fundamental change in our nation’s approach to and assumptions about patient safety seems to be in order.34 The premise of that article and this book is the same: a paradigm shift is necessary, and it must center on engaging patients for the purpose of collaborating with healthcare providers to eliminate a small but powerful subset of patient safety’s most frequently recurring problems. A decidedly narrow focus that simultaneously engages those who receive and deliver healthcare would finally place within reach the national goal of reducing hospital-induced harm by 50 percent within a five-year period—the goal that was set in 2000 and that healthcare has never come close to achieving.
There are sound reasons to narrow the focus of hospital safety programs. With zeal for improvement, hospital and industry leaders have been designing and championing safety programs that aim to tackle a multitude of issues simultaneously. They tend to blur the distinction between the broad area of quality and its narrower subset of patient safety. Although safe care represents one way of measuring overall quality of care, there are differences between safety and quality. Quality improvements have more to do with the selection and timing of clinical interventions (what and when care gets delivered) while safety efforts have more to do with the manner in which people go about the business of delivering care (how care gets delivered).
Quality-related work covers an innumerable array of complex topics and potential solutions that must be examined across a wide range of patient populations, practice settings, and clinician groups. Establishing what constitutes high-quality or evidence-based medicine is generally initiated, validated, and incorporated into the delivery system through the efforts of a select subset of healthcare professionals with ties to universities and academic medical centers. In contrast, advances in safe care generally pertain to rules, practices, and systems for getting all healthcare workers to consistently or habitually perform a small number of relatively straightforward behaviors, such as washing hands before entering and after exiting patient rooms. While some quality initiatives eventually inform safe practice, it is helpful to appreciate and bracket their unique contributions.
Laudable as comprehensive quality/safety efforts are for advancing medical science, as organization-wide programs or initiatives designed to improve day-to-day safety at the bedside, they set healthcare workers up for failure, disappointment, and disillusion. Greater return on investment can be realized by focusing on getting providers en masse to exhibit excellent performance around a defined and manageable set of safety habits. Because safety depends on patients being part of the solution, it is all the more important to focus on habits they too can recognize, request, and/or use. Yet a recent survey indicated that half of the American population is still unfamiliar with the term patient safety, although a growing number are concerned with medical mistakes—obviously not having connected the two.35
Psychologists who specialize in behavior change know that people are capable of addressing only one or two new behavioral habits or routines at a time. The same holds true for establishing organizational habits.
A Trifecta of Prevalent, Predictable, and Preventable Safety Problems
In the fifteen years since the hospital safety crisis was publicly exposed, the field of patient safety has identified specific strategies that have the capacity to eliminate the vast majority of hospital deaths due to (1) healthcare-associated infections, (2) off-the-mark procedures,36 and (3) medication administration errors. The safety strategies to prevent these three event types involve simple, quick, and practically cost-free actions, such as the use of proper handwashing, checklists, and double checks. As a group, these event types comprise the majority of all preventable deaths that occur in US hospitals, representing a safety trifecta of sorts.37
Not only does this trifecta of safety events represent the most prevalent, predictable, and preventable types of patient harm with which hospitals must cope, they also happen to constitute exactly the sort of problems that public health interventions are capable of successfully addressing. These event types clearly represent the field’s low-hanging fruit. The associated safety habits involve behaviors that healthcare workers must use regardless of the facility, so a unified public health approach has the added advantage of setting consistent expectations for physicians and staff who change jobs or work in multiple locations.
Therefore, narrowing and coordinating the focus of institutional efforts and public engagement around hospital safety’s current trifecta, or any one of its component issues, would finally place within reach the national goal of drastically cutting the rate of harm over a period of a few years. But the field must be willing to do less to achieve more, and to accommodate some shifts in power from those who deliver care to those who receive it.
Our Best Hope for Success
No matter how sophisticated the science of medicine or clinical care delivery systems become, it is an inescapable reality that ensuring patient safety is often a function of forming and sustaining simple safety habits among the millions of nurses, physicians, pharmacists, therapists, support staff, and others who affect the lives of patients every day. The breadth and volume of people who must exhibit safety habits begs for a unified, straightforward, and manageable approach. The work before us calls for a paradigm that is comprehensible to everyone regardless of rank or role and that unifies efforts of hospitals, public health, and society overall.
To the extent they are capable, providers and consumers of healthcare need to know and exercise their roles and responsibilities for eliminating healthcare’s current trifecta of safety events. Building accountability around the safety habits that can eliminate these recurring serious safety events depends on creating a greater sense that providers are accountable to their patients while also preparing patients to speak up when they observe lapses in their healthcare.
Having held leadership positions in hospitals, conducted public health research, and chaired a community-based coalition, I am confident that the field of patient safety can make a giant leap forward by expanding the safety culture model to be consistent with a more comprehensive public health framework.
Chapter 2
What Seems Too Simple toMatter Could Save Your Life
Leverage the Power of Safety Habits
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Incompetent people are, at most, 1% of the problem. The other 99% are good people trying to do a good job who make very simple mistakes and it’s the processes that set them up to make these mistakes.1
—Lucien Leape, MD, Harvard School of Public Health
Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but we rather have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit.
—Aristotle, Greek philosopher (384 BC–322 BC)
First Things First
We have a natural desire to fix everything all at once because any safety mishap that harms a patient is one too many; the life of every patient matters. Indeed, the field of patient safety must not lose sight of the full array of patient safety problems. And yet, the most efficient way to accelerate sweeping improvement is to focus on problems that affect large numbers of people and can also be solved with simple solutions. That is why it makes sense to concentrate the movement’s efforts on the trifecta of infections, procedural mistakes, and medication administration errors. Doing so can help us transform the complex problem of patient safety into manageable pieces that can be tackled systematically.
To understand the logic and value of purposefully focusing and simplifying patient safety efforts, it helps to suspend any sense of urgency to reduce all instances of harm for the sake of eradicating specific instances of harm. For a moment, take these things, which will be borne out in the coming chapters, on faith:
Healthcare has identified specific safety behaviors that can, when used consistently, eliminate or radically reduce harm associated with the most prevalent, predictable, and preventable types of patient safety problems—a trifecta of safety events.
The safety habits that can effectively prevent healthcare’s current trifecta of safety events are simple, take about two and a half minutes or less to complete, and are essentially cost-free.
Virtually every healthcare worker needs to be proficient in using the safety habits for preventing the field’s current trifecta of patient safety events.
Think about patient safety events occurring along a continuum, from those solutions that are relatively straightforward to those solutions that are extremely complex and complicated. The current trifecta anchors the easy end of the patient safety continuum.
How so? First, we already know what needs to be done to prevent healthcare-associated infections, off-the-mark procedures, and most medication administration errors. Second, the nature of the solutions to these problems involves specific behavioral actions—not complex or clinical procedures. Third, the requisite behavioral actions amount to safety habits that every healthcare professional must develop. Fourth, most patients (or their lay caregivers) can be taught to observe whether the requisite safety habits are used during clinical encounters. Finally, a proven strategy already exists for raising public awareness and mobilizing action to coordinate change around observable events and scripted actions (see chapter 6).
This analysis suggests that the greatest barrier to improving performance around some of patient safety’s most common problems is not a matter of medical science. It is a matter of getting people to do what they know is important, and this requires the aid of behavioral science. Because of the volume of providers and patients who must become engaged in the process, making a dent in the patient safety crisis will also require the aid of public health practitioners, as well as individuals, groups, and organizations that do not have a formal connection to healthcare.
When thinking about patient safety events along this continuum of challenging problems, it becomes obvious which of the field’s problems are ready to scale up for widespread success. For the reasons just described, it seems clear that each of the current trifecta events is ready for prime time. Preventing patient falls and pressure ulcers (bedsores from lying in one position for too long) may be next in line. On the one hand, patient falls and pressure ulcers are like the trifecta events in that they are highly prevalent and predictable problems whose prevention strategies primarily involve behavioral actions that must be consistently followed. On the other hand, they are unlike the trifecta events in that the preventative safety habits are required only for a subset of at-risk patients. Some hospital units already have had success reducing patient falls and pressure ulcers; however, because these event types are not as universally relevant to all patients and providers, it makes reasonable sense to tackle them after healthcare has experienced success in building the necessary organizational and community architecture to address patient safety issues that affect everyone.
The opposite end of the continuum is anchored by thorny problems, which include misdiagnosis and delays in diagnosis. Preventing diagnostic errors may be patient safety’s most challenging problem. In fact, solutions for this class of events are likely to be so numerous and idiosyncratic, relative to the type of condition and/or diagnostic tests and/or facilities involved. Because solutions are also likely to be specialty-specific, tackling diagnostic errors is arguably a matter that is more suitable to the broader field of quality improvement around clinical issues rather than the subdomain of patient safety. Healthcare will grapple with complex issues like the elimination of diagnostic errors for a long time to come, if not indefinitely. However, the existence of endlessly challenging quality and safety issues must not obscure the benefit of tackling other distinct safety issues with immediate and coordinated decisiveness.
No Bad Apples
Given that low-cost or no-cost solutions already exist for healthcare’s current trifecta, why do they persist as a major problem in virtually every hospital? Why do even the best physicians and nurses who have been trained to use essential safety habits disregard them, and why does healthcare tolerate their suboptimal performance? The truth is, getting people to consistently use known error-prevention strategies isn’t as easy as one might think.
Take the case of healthcare-associated infections that harm millions of lives and cost billions of dollars each year. Since 2001, The Leapfrog Group has been surveying hospitals about their hand-hygiene policies to see if they expect providers to adhere to standards that are known to prevent patients from picking up infections during the course of a hospital visit. According to Leapfrog’s CEO, Leah Binder, a patient’s risk of dying is two to four times lower if they receive care in a hospital that meets Leapfrog standards. If most hospitals followed the basic infection-prevention practices tracked by the Leapfrog Hospital Survey, fifty-seven thousand lives and $12 billion could be saved each year. Yet as of 2012, Leapfrog reported that, among the hospitals that agreed to be voluntarily surveyed and have their results publicly reported, only 62 percent even had hygiene policies in place.2 Fortunately, by 2013, the figure had risen by fifteen percentage points.3
That a sizable portion of reporting hospitals still doesn’t have a handwashing policy in place is disconcerting. In defense of hospitals, let’s assume they are concerned about implementing policies they cannot enforce. To be compliant with evidence-based handwashing standards, providers must wash their hands every time they enter and exit a patient’s room. Over the course of an average day, this alone could easily amount to as many as forty instances of handwashing for a typical outpatient physician, sometimes more and sometimes less for hospital physicians and staff. Even among individuals who are highly motivated to comply with best practice standards, the hustle and bustle of the dynamic hospital setting will, at times, interfere with their resolve.
Another challenge to turning essential safety behaviors into reliable habits is this: it is virtually impossible for healthcare providers to see a link between any one of their own safety lapses and an instance of direct harm to one of their patients. Sometimes this happens because the error has no discernable effect; other times it is because the error’s effect does not become apparent until later. As a result, we often maintain nono
ptimal behavioral patterns with no real feedback to spur behavior change.
Take a classic example of a child and a hot stove. The child has been told not to touch the hot stove because bad things will happen. It will hurt, he will get burned, and he may have to go to the hospital. So, for a long time, the child never touches the stove. One day, though, his bouncy ball lands on the counter, precariously perched on the edge of the hot stove. To retrieve the ball, he either needs to wait for his mother to stop what she is doing and help him or put his hand dangerously close to the hot burner to retrieve it himself. He decides to take a risk. He reaches up to the stove, puts his hand near the burner, and gets burned.
In this scenario, a risk was taken and a sufficiently unpleasant negative consequence occurred immediately. A clear connection was made between the child’s behavior and the negative consequence. You can bet that child will not be taking that risk again anytime soon. Imagine, though, if the same scenario occurred but the child placed his hand just far enough from the burner that he did not get burned. His workaround would have been successful. Not only would his risky behavior not have been punished, it would actually have been rewarded. So the child would never know how close he had come to being seriously hurt and would be more likely to take the same risk again.