Your Patient Safety Survival Guide

by Gretchen LeFever Watson

  For example, a large-scale survey of recently discharged hospital patients found that 91 percent believed they could help prevent medical errors; although patients varied with respect to their confidence or willingness to speak up about handwashing oversights, confirming their identity, and medication administration.20 A patient education intervention in four hospitals in the United Kingdom led to about a 34 percent increase in soap usage by healthcare staff, regardless of the hospital’s preintervention levels of soap usage.21 Another UK handwashing intervention with hospitalized patients found that education improved their likelihood of speaking up—especially if the providers also wore a button that said, “It’s OK to ask.”22 A 2008 review of the scientific literature found no journal article that addressed consumer involvement in patient safety initiatives in the United States or abroad. The review concluded that “evidence for consumer involvement in patient safety initiatives is limited and involvement of consumers is unlikely to occur without active recruitment programs.”23

  In the years since that review, many hospitals, healthcare systems, and government agencies have begun to more aggressively develop strategies to engage patients. To more effectively promote patient and family engagement in hospital settings, the Agency for Healthcare Research and Quality contracted the American Institutes for Research to review and report on the status of tools and practices that were currently in use. The review included team input, key informant interviews, and a comprehensive scan of the scientific and gray literature—including material available on 110 websites and 330 tools.24

  In spite of the rapid expansion of literature and materials, the American Institutes for Research found they were universally inadequate to the task at hand. The institute identified four major gaps with existing patient-engagement efforts: the information was not attuned to patient and family member experiences; lacked concrete, actionable support for individual patients (and professionals) to engage in specific behaviors; omitted complementary strategies for patients and those who care for them; and failed to include specific guidance for hospitals to implement recommended engagement practices. Among the handful of tools with content deemed potentially useful, none was found to be ready for use in its current form. Low health literacy was identified as a significant barrier to the effectiveness of materials in print.25

  Health literacy refers to a patient’s ability to read, understand, and act upon health information. It requires more than the ability to read. It requires reading, listening, analytic, and decision-making skills, and the ability to apply such skills to health situations. Health literacy emphasizes the importance of clear communication between healthcare providers and their patients, recognizing that both the patient’s and the provider’s skills affect comprehension, and it is a dynamic construct that is affected by situational factors.26 In addition to the choice of content (the amount of information or the complexity of information), health literacy can be compromised by design elements (small print, limited white space).27

  Research has documented that regardless of their reading level, patients prefer medical information that is easy to read and understand.28 For people who do not have strong reading skills, access to easy-to-read material is not just desirable, it is essential. Attending to content and design issues of patient advisories is critical because the average American reads at the ninth-grade level, while one in five American adults read at the fifth-grade level or below.29 Yet most healthcare advisories have been written for above the tenth-grade level, leaving up to ninety million Americans unlikely to adequately comprehend existing materials.30

  Over one-third of hospitalized Americans have low health literacy, which is not surprising because the problem is more acute among the elderly, minimally educated, and chronically ill populations31—the very people who are at increased risk for being hospitalized. In fact, more than two-thirds of Americans over the age of sixty and up to half of minority populations have literacy skills that may be either inadequate or marginal for comprehending existing patient-advisory pamphlets.32 As such:

  Most of the literature on patient and family engagement roles focuses on what patients could do (or what researchers and policymakers want patients to do) instead of discussing what behaviors patients and family members currently engage or would be willing to engage during clinical encounters.33

  Even among professionals who have been involved with the development of notable patient safety advisories, some openly doubt whether healthcare providers would regularly discuss the advisories with patients, reinforce the advisories’ messages, or even support their use.34

  Furthermore, the timing of the delivery of patient-oriented education has not been ideal. Because patients experience heightened states of anxiety during hospital stays, it is reasonable to expect the health literacy among all patients, including the highly educated, to plummet upon admission. Therefore, even with access to the best patient advisories, waiting until people are hospitalized as the primary way to encourage an active role in the delivery of safe care amounts to too little too late.35 Introducing patients to safety expectations through written materials during or shortly before a hospitalization simply doesn’t constitute genuine patient engagement.

  Whereas greater patient (or consumer) engagement in US healthcare has been a matter of considerable discussion at a national level, hospitals have responded by branding and printing tons of materials directed at patients. But very few hospitals have actually engaged with the communities they serve to identify and implement realistic ways for patients to fully assert their rights and responsibilities as partners in safe care.

  Empowering People to Speak Up for Safety

  Speaking up for safety refers to someone raising concerns for the benefit of safety and quality care upon becoming aware of risky or deficient action on the part of others.36 Empowering people to speak up for safety is a challenge in every type of organization, and there is ample evidence to indicate that this represents a serious problem for the healthcare industry. Since 2007, hospitals around the country have been completing the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey. It allows hospitals to benchmark their culture against other hospitals. In 2011, over one thousand hospitals completed the survey, and AHRQ contracted an independent organization to examine the degree of improvement in the culture of safety among US hospitals from 2007 to 2011. The results indicated that there had been no overall progress, with half of the employees still saying they did not feel free to speak up for safety. They reported experiencing or fearing they would experience punitive responses from the administration for identifying and reporting errors, believing that reporting mistakes would be held against them and threaten their job security.37

  If, after years of effort, healthcare employees still believe they cannot speak up for safety, why should we expect patients to do so? Actually, a 2014 review of the literature on studies that sought to increase people’s ability to speak up for safety provides support for the idea. Authors of the comprehensive review determined that healthcare worker decisions to speak up are influenced by their degree of perceived fear of administrative retaliation (getting fired), motivation based on the extent to which they believe patient safety might be at risk, and clarity about the proper course of action (ambiguous versus clear-cut expectations).38 Patients do not need to be worried about being fired by hospital administrators, which lays the first concern to rest. Public health–oriented campaigns could successfully address the other two issues (motivation and perceived risk). Such campaigns would also have the added advantage of focusing exclusively on simple, effective safety habits as opposed to more complex quality issues that require a myriad of judgment calls involving a high degree of uncertainty about correct actions. Of course, such campaigns must include complementary efforts to prepare providers to respond favorably when patients do speak up for safety.

  Involving a community—patients, prospective patients, lay caregivers, patie
nt advocates, and hospital visitors—to eliminate any one of healthcare’s trifecta of current safety issues would constitute realistic and genuine patient engagement. The process would equip patients with a specific and important role as a member of their care team—the very thing that healthcare leaders have been seeking.

  Putting It All Together

  Mastering safety habits is something every healthcare worker must do, something every patient wants them to do, and something the public can help them do. But how can this be achieved? In the process of gathering information for a comprehensive infection control and prevention project, Johns Hopkins conducted a brief pilot study to gain insights for improving handwashing compliance. Study results underscored the fact that getting patients to speak up for safety is not always easy. Staff collected information from patients in one of their outpatient clinics. Results of their face-to-face pilot survey revealed that 86 percent of patients indicated that they would be willing to be a hand-hygiene observer, although almost one-third fewer patients (56 percent) expressed a willingness to speak up if they saw a provider fail to use proper hand hygiene.39

  Empowering patients to know when and how to take action is precisely the focus of many successful public health campaigns, but this is not what hospitals alone are prepared to do well. However, community-based coalitions, which typically include hospital-community partnerships, represent a well-established and proven method for engaging consumers in public health initiatives across a wide range of topics. Community-based coalition work arguably represents a missing component of a comprehensive framework for tackling the hospital safety crisis, especially for problems as prevalent, predictable, and preventable as those comprising the current hospital safety trifecta.

  Whatever reasons have existed for treating hospital safety as an in-house matter, it is time to take this issue to the streets. Doing more of the same and expecting better results is not rational. Besides, the essential components of a successful public health campaign to improve patient safety have already been established, including:

  specific safety habits for eliminating or radically reducing common medical mistakes

  proven behavioral science principles to facilitate the mastery of safety habits

  experience using community coalitions to mobilize support for health-related behavioral changes across large groups of people and organizations.

  Understanding the problem of patient safety within a broader public health framework that centers on patient engagement would represent a paradigm shift that supports the integration and application of knowledge from a number of fields—something that is evidently necessary. Recent testimonials on the Joint Commission’s Center for Transforming Healthcare’s website speak to the value of a new paradigm of this nature.40

  The hand-hygiene initiative focuses attention on the problem of hand hygiene and offers an evidence-based way to measure the problem, implement interventions, and measure improvement. The challenge is making handwashing a habit that all healthcare workers do without even thinking about it.

  —Linda Maragakis, MD, MPH, Johns Hopkins Medical Institutions

  We will know if we have been successful with the hand-hygiene initiative when we see the culture begin to change in our organizations. I hope that we will see people reminding each other to wash their hands, and those reminders will not be interpreted as punitive, but instead as teamwork.

  —Beth Lanham, BSN, RN, Froedtert Hospital

  Transforming healthcare means taking what we have done; looking at it in a new way; taking it in a new direction; and, rather than making incremental improvement, making revolutionary improvement.

  —Brian Regan, PhD, New York Presbyterian Healthcare System

  The behaviors that are required to eliminate the most prevalent, predictable, and preventable hospital safety events represent what could become healthcare’s keystone habits. Keystone habits are those that convey “success doesn’t depend on getting every single thing right, but instead relies on identifying a few key priorities and fashioning them into powerful levers.”41 Once we figure out how to develop and sustain these habits, we will have gone a long way toward restoring confidence that it is possible to keep patients safe. Without them, we will continue to spin our wheels with too little progress for all the energy expended.

  Chapter 3

  Make It a Bad Day to Be a Bug

  Prevent the Spread of Dangerous Infections

  Johanna Daly

  Johanna Daly was a healthy and active sixty-three-year-old woman when she slipped on an icy sidewalk when leaving a restaurant. She broke her shoulder and underwent a scheduled operation a few days later. The surgery and initial recovery went as planned. A young intern visited her hospital room to check the surgical incision. Without washing his hands or donning gloves, he removed her bandages and squeezed the incision. It looked good, and she was scheduled for discharge. Over the next few days, the surgical site became unbearably painful. Four days later, when seen in an emergency department, a physician drained over a quart of pus from the wound. It was necessary to schedule Johanna for emergency surgery to further clean the infected wound. It turned out that Johanna had contracted a virulent and antibiotic-resistant infection or “superbug” called MRSA (Methicillin-resistant Staphylococcus aureus, pronounced mursa). Being infected with MRSA led to a rapid decline in her health. Within days of the second surgery, Johanna’s organs began to shut down and she was placed on a ventilator in an intensive care unit, where she remained until her death several months later.1

  Superbugs

  Hundreds of people suffer similar fates as Johanna Daly every day. All of us are potential victims of healthcare-associated infections. These deadly bugs have long been known to lurk around inpatient facilities, especially hospitals, nursing homes, and rehabilitation centers. Of growing concern is that some of these infections involve superbugs that are highly resistant to antibiotic treatment due to the widespread overuse of antibiotics. Sometimes these bugs are stronger than any weapon we have to fight them.

  Healthcare-associated infections may represent the most common patient safety event, killing up to one hundred thousand US hospital patients each year. And this is only the tip of the iceberg. This number does not include the nearly two million people who are infected but manage to survive—like NBA superstar Grant Hill. In 2003, this strong, healthy, young athlete nearly died from a MRSA infection acquired in the hospital during routine ankle surgery. The infection ate a hole in his ankle, required a skin graft and an extended hospitalization, and was followed by a six-month course of intravenous antibiotic treatment.

  Furthermore, these superbugs are becoming common in outpatient settings. A couple of years ago, I picked one up as a result of a brief scoping procedure that was performed in an outpatient clinic. Being in great health and not having been hospitalized, nobody expected me to pick up a dangerous superbug that normally affects critically ill patients. In fact, the infection I contracted is a superbug that is commonly referred to as an “ICU bug” because it is historically found only among people being cared for in intensive care units.

  I recovered, but it took a year of misguided treatment before the unexpected source of my symptoms was discovered. Adding to my frustration (and discomfort), appropriate treatment was delayed partly because of the failure of a hospital laboratory to process a test and a breakdown in communication between a hospital emergency department and a specialist—this occurred in spite of my attempt to prevent such a mistake.

  Unfortunately, this scenario is likely to play out frequently. Superbugs are now spreading beyond hospital walls and into outpatient care settings. Scarier still, superbugs are creeping their way into community settings, like locker rooms, classrooms, and daycare centers.

  Clean Care Is Safe Care

  Many people think that eliminating healthcare-associated infections is the sort of problem that requires expensive,
high-tech solutions. We certainly do have emerging tools like custom-engineered germ-killing counter surfaces and $100,000 robots that scan hospital rooms to kill detected germs.2 The fact is, however, that the single most effective solution for preventing the spread of infection involves proper handwashing—plain and simple.3

  In short, everyone—providers, hospital support staff, visitors, and others—should wash their hands every time they enter and exit an ICU and every time they enter and exit any patient room. A successful national handwashing campaign would save many of the one hundred thousand lives that end every year due to healthcare-associated infections. It would also eliminate more than $150 million in avoidable healthcare expenditures.4 Based on published data, an average two-hundred-bed hospital incurs over $1.7 million in annual MRSA infection expenses that are attributable to handwashing noncompliance. A mere 1 percent increase in hand-hygiene compliance can result in a savings of almost $40,000 per year for a two-hundred-bed hospital.5

  So, What Gives?

  Proper hand hygiene could eliminate the vast majority of hospital-acquired infections (and associated human and financial costs), but after a decade of intense effort to establish consistent and proper hand hygiene, on average, only about 50 percent of doctors and nurses in leading hospitals wash their hands as needed.6 Sometimes rates have been shown to be as high as 90 percent,7 but experience proves that such findings tend to be inflated due to observation strategies that alert providers to when they are being monitored and reporting that is skewed by virtue of outcomes being tied to employee bonuses. At any rate, why is proper hand hygiene characteristically low? The problem is actually a complex one that healthcare has struggled with, to varying degrees, for hundreds of years.

  A Little Handwashing History