Essential Pieces of the Puzzle
Medical research has identified critical safety habits that, if used consistently, can drastically reduce or eliminate the trifecta of issues that comprise patient safety’s low-hanging fruit—healthcare-associated infections, off-the-mark procedures, and medication administration errors.
Behavioral science (psychology) has taught us what needs to be done to establish desirable habits and to make them stick.
Public health has established that community-based coalitions and related strategies are effective for mobilizing and coordinating changes in patient and provider behaviors.
It is tempting to detail how a community might tackle the crisis, but communities vary greatly in terms of capacity and resources to support a coalition, so it is not wise to do so. Moreover, greater joy, ingenuity, and sustainability are likely to ensue when communities decide for themselves which issues they want to tackle and then determine what will work for their particular circumstances. There is no right answer, but there is a universally urgent need to uncover solutions that are currently invisible in plain sight.
Taking Action
Sometimes community coalitions form at the local level and are then replicated across broader geographic regions with financial support being secured through a hodge-podge of mechanisms. In other instances, a national organization serves as the instrument for forming local coalitions by providing funding to communities throughout the country, as happened, for example, with a portion of the funding from the 1998 Tobacco Master Settlement Agreement.
From the very beginning, the National Patient Safety Foundation has been a central voice in the patient safety movement, and its current direction is consistent with the idea of creating community coalitions to accelerate progress. More than any other agency or organization, this foundation may be ideally positioned to facilitate and support the formation of community coalitions in communities around the United States. Furthermore, in 2007, the National Patient Safety Foundation formed an institute for a purpose that supports the ideas expressed in this book:
The NPSF Lucien Leape Institute was formed in 2007 to provide strategic vision for improving patient safety. Composed of national thought leaders with a common interest in patient safety, the Institute functions as a think tank to identify new approaches to improving patient safety, call for the innovation necessary to expedite the work, create significant, sustainable improvements in culture, process, and outcomes, and encourage key stakeholders to assume significant roles in advancing patient safety.29
As a think tank, the Lucien Leape Institute could serve as the repository of lessons learned and thereby the vehicle to expedite the diffusion of innovation. Equally important, the institute could become the one-stop resource for technical support to help communities understand how to build effective patient safety coalitions. Many other nonprofit organizations could be equally appropriate national champions or sponsors, perhaps especially Leapfrog or the National Business Coalition on Health, because they too are heavily invested in the consumer side of improving patient safety.
Baby Steps and Giant Leaps
By the time you read this book, perhaps a national organization will have come onboard with the idea of supporting the formation of patient safety coalitions in communities across the United States. Regardless, there is no reason to wait. All it takes to get started is to have a conversation with others to discover who else might be able to help champion patient safety improvements in your own backyard. You may discover people who have prior coalition experience or other relevant experience. Although it is overused, there is a famous Margaret Meade quote that sums up the message of this chapter:
Never doubt that a small group of thoughtful committed citizens can change the world; indeed, it’s the only thing that ever has.
Admittedly, the idea of bringing members of competing healthcare facilities together with patients and other members of the public may be threatening to business and community leaders. Healthcare is a competitive business, and there are a variety of metrics over which healthcare organizations in any given community must and will compete, including certain safety metrics. Recall that, as discussed in the beginning of this book, The Leapfrog Group pushes for greater transparency around hospital safety metrics as a way to allow market forces to trigger giant leaps forward in the journey toward safe care.
Although competition is healthy and can spur innovation, there are also circumstances and issues over which cooperation—rather than competition—is in the best interests of everyone. Selecting a single patient safety issue to bring key stakeholders together is likely to increase their willingness to cooperatively seek solutions that affect everyone in the community. One of the few community-oriented efforts to improve patient safety was organized by Dr. Kathleen Leonhardt of Aurora Health Care.30 Leonhardt indicated that selecting a single issue created a turning point in collaboration among otherwise competitive organizations.31
When a community discovers workable solutions to one of its seemingly insurmountable patient safety problems, it will have strengthened its capacity and resolve to tackle other issues in due time—provided that the unique interests of each member organization were respected along the way. Meanwhile, the building of local patient safety coalitions may be the best—or perhaps the only—way to more rapidly create a community where patients and those who care for them are free from harm.
Building community coalitions to facilitate the adoption of a more patient-centric view of safety and to identify workable solutions may seem like a tall order, but the rewards for doing so would be great. Consider how Dr. James L. Reinertsen, a prominent healthcare consultant and former CEO of Beth Israel Deaconess Medical Center in Boston, summarized the value of genuine patient engagement:
We have observed that in a growing number of instances where truly stunning levels of improvement have been achieved, organizations have asked patients and families to be directly involved in the process. And those organizations’ leaders often cite this change—putting patients in a position of real power and influence, using their wisdom and experience to redesign and improve care systems—as being the single most powerful transformational change in their history. Clearly, this is a leverage point where a small change can make a huge difference.32
Ironically, much of the work necessary to improve patient safety within hospitals and other healthcare facilities must occur outside these organizations through public health initiatives. Local patient safety coalitions fit the bill. They can raise awareness, motivate civic action, and offer hospital patients manageable steps to ensure safer care for themselves and others. The best return on investment may be realized by first addressing the most prevalent, predictable, and preventable types of patient safety events. Doing so will require a paradigm shift that will unify efforts from healthcare systems, public health, and society overall.
If you’ve read this far, you care about patient safety. Hopefully, you will initiate a conversation about the need to improve patient safety with at least one other person who lives or works in your community. If the two of you continue to have conversations about this pressing public health crisis until one or both of you encounters someone who—by virtue of position, knowledge, resources, or connections—can help create a patient safety coalition in your community, you will have taken small steps that can clear the path for giant leaps toward creating a world where patients and those who care for them are free from harm.
In the words of the National Patient Safety Foundation: “We need to mobilize. We are all in this together. Let’s get the work done now.”33
Chapter 7
Acceptance, Apology, and Forgiveness
Safeguard the Lives of Patients and Healthcare Providers
It is a capital mistake to theorize before one has data.
—Arthur Conan Doyle, Memoirs of Sherlock Holmes1
There could be no prog
ress until enough people could be made dissatisfied—and this could be done only when they were brought to think beyond the limits to which they were accustomed.
—Thomas Edison, American inventor (1847–1931)2
Nurse Hiatt
Kimberly Hiatt had twenty-four years of nursing experience, impressive credentials, and numerous certifications when her employing hospital praised her as a “leading performer.” Two weeks later, Kimberly mistakenly administered 1.4 grams of calcium chloride (CaCl2) to an eight-month-old infant. That dose was ten times greater than what was ordered. Kimberly’s mistake stemmed from a calculation error she made while being distracted by conversation with a coworker, which led her to confuse 1.4 grams and 140 milligrams. As soon as Kimberly discovered the error, she reported it to the staff and documented it in the hospital’s electronic record system: “I messed up. I’ve been giving CaCl for years. I was talking to someone while drawing it up. Miscalculated in my head the correct mls according to the mg/ml. First med error in 25 yrs. of working here. I am simply sick about it. Will be more careful in the future.” Several days after this event, the baby died. Although it was not clear that Kimberly’s error caused the baby’s death, the hospital fired her. When the state’s nursing board learned of Kimberly’s error, they required her to pay a fine to the board and placed her on a four-year probationary period, during which time she was required to be supervised while dispensing medication. Not surprisingly, Kimberly had difficulty finding another job. A few months after being fired and unable to secure a new position, Kimberly committed suicide.3
The Ripple Effect
Initially there were only going to be six chapters in this book, but the more I talked about how common human error is in healthcare, the more necessary it was to foster appreciation for how devastating mistakes can be for healthcare providers, how often adverse outcomes stem from honest error, and how misguided it is to rush to judgment about who or what was responsible for the harm that sometimes befalls patients. Your Patient Safety Survival Guide is about uniting patients and healthcare providers to safeguard lives—not about inducing a sense of helplessness or misplaced anger. It would have been incomplete without this final chapter about inviting patients and providers to consider constructive actions they can take when patient safety events occur.
If you Google the Nurse Hiatt case, you will come across a photograph of Kimberly in her nursing scrubs; looking vibrant, fit, and happy—the very sort of image that might come to mind when you think about a competent nurse and a “leading performer.” The photo does not depict a person you would expect to be fired or to commit suicide; however, in the absence of support, a patient safety event can have tragic consequences for any provider. Recent analyses indicate that following an adverse event, the majority of providers experience psychological distress, some seriously contemplate leaving the field, and a small portion never recover.4 This ripple effect, called the second victim phenomenon, refers to a period of intense or prolonged anguish or guilt that results from witnessing or contributing to an event that caused harm to a patient.5
It was a Johns Hopkins physician—Albert Wu, MD—who first introduced the medical field to the second victim phenomenon. Later (in the same year that To Err Is Human was published), Wu courageously broke the longstanding silence about the agony providers feel in the face of a medical error, giving voice to their previously concealed vulnerability.
Provider Agony in the Face of Error
Virtually every practitioner knows the sickening realization of making a bad mistake. You feel singled out and exposed—seized by the instinct to see if anyone has noticed. You agonize about what to do, whether to tell anyone, what to say. Later, the event replays itself over and over in your mind. You question your competence but fear being discovered. You know you should confess, but dread the prospect of potential punishment and of the patient’s anger. You may become overly attentive to the patient or family, lamenting the failure to do so earlier and, if you haven’t told them, wondering if they know.
Sadly, the kind of unconditional sympathy and support that are really needed are rarely forthcoming. While there is a norm of not criticizing, reassurance from colleagues is often grudging or qualified. . . .
Further, there are no institutional mechanisms to aid the grieving process. Even when mistakes are discussed at morbidity and mortality conferences, it is to examine the medical facts rather than the feelings of the patient or physician. In the absence of mechanisms for healing, physicians find dysfunctional ways to protect themselves. They often respond to their own mistakes with anger and projection of blame, and may act defensively or callously and blame or scold the patient or other members of the healthcare team. . . . My observation is that this number includes some of our most reflective and sensitive colleagues, perhaps most susceptible to injury from their own mistakes.6
Later, a director of the Agency for Healthcare Research and Quality reinforced the importance of attending to the second victim phenomenon, describing it as a wounding burden:
The burden that healthcare providers feel after a patient is harmed, manifesting in anxiety, depression, and shame, weighs so heavily on providers that they themselves are wounded by the event.7
Because involvement in patient safety events harms the people who are available to care for us in our hours of need and because such involvement can negatively impact their ability to care for subsequent patients, some have described caring for second victims to be a moral imperative.8 Engendering a sense of duty to care for providers whose actions contribute to serious patient safety events requires that we relinquish the unrealistic notion that our healthcare providers and the systems in which they work allow them to consistently perform without error.
Letting Go of Unrealistic Expectations
It is important to remember that every human being makes mistakes. That means every healthcare provider will make mistakes. Anyone who cares for enough patients will eventually be involved in a seriously harmful mistake. In fact, a recent national survey of hospital-based pediatricians and pediatric residents found that 93 percent of them acknowledged having been personally involved in an error at some point during their training or career.9 Think about it: if a hospital provider were to see an average of four patients in a twelve-hour shift (a low caseload), in a twenty-year career he or she will have cared for over eleven thousand patients.10 This means that virtually every hospital provider will be involved in numerous patient safety events, some of which will have devastating consequences. In fact, 40 percent of today’s providers report that they have been involved in a patient safety event in the past year, and some evidence suggests the rate may be even higher.11
Just because human error is inevitable and will, at times, cause serious harm to patients, healthcare has not let itself off the hook. To the contrary, as discussed in chapters 1 and 2, for the past two decades the industry has been diligently seeking to eliminate harm stemming from common human error. By the same token, just because it is theoretically possible to build safeguards into a system to catch errors, every medical error doesn’t necessarily represent negligence on the part of the system or its providers. In a timeless paper, medical ethicist Samuel Gorovitz and world-renowned moral philosopher Alasdair MacIntyre reasoned why a just and fair response to healthcare-induced harm must be evaluated against the state of scientific knowledge.12 In essence, Gorovitz and MacIntyre argue that as the state of scientific or medical knowledge improves over time, so too must our view of what constitutes negligence evolve.
Healthcare-associated infections are a clear case in point. Today, each infection that a patient picks up during the course of their hospital care is considered to be a patient safety event. Yet for more than one hundred years after we knew how to prevent the spread of most of these infections, the industry wrote them off as the cost of doing business. As a psychologist and public health practitioner, I have always been interested in how scientific knowled
ge is translated into routine clinical practice. This turns out to be a slow, uneven, and imperfect process. Just because a researcher has published a study that demonstrates how to eliminate a certain type of patient harm doesn’t mean that every professional will immediately have a working knowledge of that discovery—a point that is driven home by the fact that Americans receive evidence-based care barely more than half the time.13
In today’s world, translating medical discoveries into medical practice is complicated by the volume and complexity of the scientific literature. As of 2012, there were approximately twenty-eight thousand scholarly journals that publish close to two million scientific, technical, and medical articles per year—about half of which are in English.14 To further understand this complexity, Professor MacIntyre recently reminded me of the incredibly important and relevant work by the world’s premier scientists. Among other things, John P. A. Ioannidis is famous for demonstrating the troubling fact that half of all medical research claims that get published can be proven to be false.15 Consider also that relatively few physicians read original scientific papers or have been adequately prepared to critique published results. This reality is conveyed in two compelling books about modern medicine: Overtreated by Shannon Brownlee and Doctored by Sandeep Jauhar.16 So perhaps it should not be hard to comprehend why patients receive evidence-based care only about half the time they seek treatment. Over forty years ago, Gorovitz and MacIntyre said that we need a “more rational societal response to the reality of errors in clinical practice”17 and this is all the more true today (arguably we also need a better way to ensure that clinical providers become more proficient at applying true medical and scientific discoveries).18
Here is a bit of medical history to put into perspective how scientific knowledge becomes common practice. In 1961, 90 percent of physicians surveyed preferred not to tell cancer patients about their diagnosis; by 1977, 97 percent felt the opposite. The shift from shielding patients from knowing their diagnosis to teaching them about it had virtually nothing to do with research or policy. The shift was facilitated principally by a change in physician training.19 This shift reinforces the observation that determining culpability requires a great deal more consideration than the state of scientific knowledge.
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