Your Patient Safety Survival Guide

by Gretchen LeFever Watson

  Ultimately we cannot deliver the safest possible care unless we foster an environment in which healthcare workers have a safe place to grapple with the impact of their involvement in adverse events. If our legal structures create a chilling effect on these communications, then healthcare professionals, patients, and the system as a whole suffer in the long run.70

  United, We All Gain

  Just think of the agony and cost to patients, providers, institutions, and society that could be averted through greater openness about medical mistakes. As Gorovitz and MacIntyre noted four decades ago:

  It follows that injury is no proof of culpability. If physicians were to act as if they recognized this point, they might become far less reluctant to acknowledge, systematize, and learn from injury. But that would require a widespread willingness on the part of patients also to acknowledge this point, and thereby lower their expectations about what physicians can accomplish, and to refrain from assuming, even in the disappointment or despair that attends iatrogenic [healthcare-induced] injury, that the physician is culpable.71

  We truly are in this together. The sooner we accept the imperfect nature of healthcare and apologize for mistakes when they do occur, the more we will learn from our mistakes and the quicker and better we will recover from the physical, emotional, financial, and societal wounds that medical errors can cause. In the words of Alexander Pope, a seventeenth-century poet: “To err is human; to forgive, divine.”

  Notes

  Chapter 1

  1. Donald M. Berwick, 2016. Permission granted via November 15, 2016, email from Donald Berwick to ascribe this quote to him.

  2. Alan L. Mackay, A Dictionary of Scientific Quotations (Bristol, UK: Institute of Physics Publishing, 1991).

  3. J. T. James, “A New, Evidence-Based Estimate of Patient Harms Associated with Hospital Care,” Journal of Patient Safety 9, no. 3 (2013).

  4. Martin A. Makary and Michael Daniel, “Medical Error—the Third Leading Cause of Death in the US,” BMJ 353 (2016).

  5. L. Binder, “Stunning News on Preventable Deaths in Hospitals,” Forbes Magazine, September 23, 2013, http://www.forbes.com/sites/leahbinder/2013/09/23/stunning-news-on-preventable-deaths-in-hospitals/.

  6. L. L. Leape et al., “Preventing Medical Injury,” Quarterly Review Bulletein 19, no. 5 (1993).

  7. R. Scott, “The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention,” ed. Centers for Disease Control and Prevention (CDC, 2009).

  8. C. Andel et al., “The Economics of Health Care Quality and Medical Errors,” Journal of Health Care Finance 39, no. 1 (2012).

  9. D. C. Classen et al., “‘Global Trigger Tool’ Shows That Adverse Events in Hospitals May Be Ten Times Greater Than Previously Measured,” Health Affairs 30, no. 4 (2011).

  10. Judith H. Hibbard et al., “Can Patients Be Part of the Solution? Views on Their Role in Preventing Medical Errors,” Medical Care Research and Review 62, no. 5 (2005).

  11. E. G. Campbell et al., “Professionalism in Medicine: Results of a National Survey of Physicians,” Annals of Internal Medicine 147, no. 11 (2007).

  12. Institute of Medicine, Patient Safety: Achieving a New Standard of Care (Washington, DC: National Academies Press, 2004).

  13. Campbell et al., “Professionalism in Medicine.”

  14. Occupational Safety and Health Administration, “Worker Safety in Your Hospital,” https://www.osha.gov/dsg/hospitals/documents/1.1_Data_highlights_508.pdf.

  15. James, “A New, Evidence-Based Estimate of Patient Harms Associated with Hospital Care.”

  16. Megan McArdle, The Up Side of Down: Why Failing Well Is the Key to Success (New York: Penquin Books, 2015).

  17. J. M. Kane, M. Brannen, and E. Kern, “Impact of Patient Safety Mandates on Medical Education in the United States,” Journal of Patient Safety 4, no. 2 (2008).

  18. J. N. Deis et al., “Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement,” in Advances in Patient Safety: New Directions and Alternative Approaches, ed. K. Henriksen, J. B. Battles, and M. A. Keyes (Rockville, MD: Agency for Healthcare Research and Quality, 2008); Lucien Leape Institute, “Unmet Needs: Teaching Physicians to Provide Safe Patient Care” (Boston, MA: National Patient Safety Foundation, 2010).

  19. L. T. Kohn, J. M. Corrigan, and M. S. Donaldson, To Err Is Human: Building a Safer Health System (Washington, DC: Institute of Medicine, 1999).

  20. Kohn, Corrigan, and Donaldson, To Err Is Human.

  21. L. L. Leape, “Scope of Problem and History of Patient Safety,” Obstetric and Gynecological Clinics of North America 35 (2008).

  22. Binder, “Stunning News on Preventable Deaths in Hospitals.”

  23. L. L. Leape and D. M. Berwick, “Five Years after To Err Is Human: What Have We Learned?” JAMA 293, no. 19 (2005).

  24. G. H. Burke, G. B. LeFever, and S. M. Sayles, “Zero Events of Harm to Patients: Building and Sustaining a System-Wide Culture of Safety at Sentara Healthcare,” Managing Infection Control (2009), http://www.yoursls.com/Culture-Safety-Healthcare.pdf.

  25. R. Grol, D. M. Berwick, and M. Wensing, “On the Trail of Quality and Safety in Health Care,” BMJ: British Medical Journal 336, no. 7635 (2008); K. Jewell and L. McGiffert, “To Err Is Human—to Delay Is Deadly: Ten Years Later, a Million Lives Lost, Billions of Dollars Wasted,” Consumers Union: Nonprofit Publishers of Consumer Reports (2009), http://safepatientproject.org/pdf/safepatientproject.org-to_delay_is_deadly-2009_05.pdf.

  26. D. Charles, M. Gabriel, and M. F. Furukawa, “Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008–2013,” ONC, https://www.healthit.gov/sites/default/files/oncdatabrief16.pdf.

  27. William F. Bria, “The Electronic Health Record: Is It Meaningful Yet?” Mayo Clinic Proceedings 86, no. 5 (2011); D. F. Carr, “Electronic Health Records: First, Do No Harm?” InformationWeek (2014), http://www.informationweek.com/healthcare/electronic-health-records/electronic-health-records-first-do-no-harm/a/d-id/1278834; J. Sidorov, “It Ain’t Necessarily So: The Electronic Health Record and the Unlikely Prospect of Reducing Health Care Costs: Much of the Literature on Ehrs Fails to Support the Primary Rationales for Using Them,” Health Affairs 25, no. 4 (2006).

  28. Stacy Parker, “Health Care Hero Awards: Corporate Achievements in Health Care,” Inside Business, February 17, 2012; Robert Wachter, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (New York: McGraw-Hill, 2015).

  29. Wachter, The Digital Doctor.

  30. M. R. Chassin and J. M. Loeb, “High-Reliability Health Care: Getting There from Here,” Milbank Quarterly 91, no. 3 (2013).

  31. R. M. Wachter to Wachter’s World, February 18, 2013, http://blogs.hospitalmedicine.org/Blog/is-the-patient-safety-movement-in-danger-of-flickering-out/ http://community.the-hospitalist.org/2013/02/18/is-the-patient-safety-movement-in-danger-of-flickering-out/.

  32. Wachter’s World.

  33. Comment regarding Denham: I experienced the same ingratiating treatment in 2013 when Denham was interested in connecting with the $16 million HITECH grant that I was directing for the purpose of establishing leadership training for healthcare professionals involved with implementing new technology in their facilities. To this day, it is disconcerting to look back and wonder whether his motives were pure. In spite of his acts of impropriety, Denham did make positive and lasting contributions to the field of patient safety.

  34. G. L. Watson, “The Hospital Safety Crisis: Unifying Efforts of Healthcare Systems, Public Health, and Society,” Society 53, no. 4 (2016).

  35. Hibbard et al., “Can Patients Be Part of the Solution?”

  36. Comment regarding off-the-mark procedure terminology: off-the-mark procedures refer to what the field typically calls wrong-site surgeries. For reasons explained in chapt
er 5, use of the term off-the-mark procedures eliminates the considerable confusion that has stemmed from the use of the term wrong-site surgeries.

  37. Comment regarding frequency of off-the-mark procedures: although off-the-mark procedures occur much less often than healthcare-associated infections and medication errors, this is one of the most preventable types of medical error. All three types of error can be prevented with consistent use of specific behaviors that laypersons could and should learn to observe and/or request. Together, they comprise as much as half of all medical errors.

  Chapter 2

  1. Comment regarding Lucien Leape quote: Countless presentations and articles ascribe this quote to Dr. Lucien L. Leape, a physician at Harvard School of Public Health who has been a leader of the patient safety movement. I have not been able to document the original source, but I have requested permission to ascribe this quote to Dr. Leape.

  2. Leah Binder, “The Leapfrog Annual Hospital Survey,” personal communication email, 2013.

  3. Leah Binder and William H. Finck, “Results of the 2013 Leapfrog Hospital Survey: Executive Summary,” 2015, http://www.leapfroggroup.org/sites/default/files/Files/2013LeapfrogHospitalSurveyResultsReport.pdf.

  4. Centers for Disease Control and Prevention, “General Information about MRSA in the Community,” Centers for Disease Control and Prevention.

  5. James Reason, “Human Error: Models and Management,” BMJ: British Medical Journal 320, no. 7237 (2000).

  6. C. Duhigg, The Power of Habit: Why We Do What We Do in Life and Business (New York: Random House, 2014).

  7. G. Rubin, Better Than Before: Mastering the Habits of Our Everyday Lives (New York: Crown Publishers, 2015).

  8. Gordon Kraft-Todd et al., “Promoting Cooperation in the Field,” Current Opinion in Behavioral Sciences 3 (2015).

  9. Jennifer Jacquet, Is Shame Necessary?: New Uses for an Old Tool (New York: Random House, 2015).

  10. Jacquet, Is Shame Necessary? 173.

  11. Josep Call et al., “Domestic Dogs (Canis Familiaris) Are Sensitive to the Attentional State of Humans,” Comparative Psychology 117, no. 3 (2003).

  12. J. H. Hibbard, J. Stockard, and M. Tusler, “Does Publicizing Hospital Performance Stimulate Quality Improvement Efforts?” Health Affairs 22, no. 2 (2003).

  13. I. M. Rosenstock, V. J. Stretcher, and M. H. Becker, “Social Learning Theory and the Health Belief Model,” Health Education Quarterly 15, no. 2 (1988).

  14. S. B. Fawcett et al., “Using Empowerment Theory in Collaborative Partnership for Community Health and Development,” American Journal of Community Psychology 23, no. 5 (1995); D. J. McCloskey et al., “Community Engagement: Definitions and Organizing Concepts from the Literature,” ed. Public Health Practice Program Office (Atlanta, GA: Centers for Disease Control and Prevention, 2015).

  15. Angela Coulter and Jo Ellins, “Effectiveness of Strategies for Informing, Educating, and Involving Patients,” BMJ: British Medical Journal 335, no. 7609 (2007).

  16. Donald M. Berwick, “What ‘Patient-Centered’ Should Mean: Confessions of an Extremist,” Health Affairs 28, no. 4 (2009).

  17. Center for Advancing Health, “A New Definition of Patient Engagement: What Is Engagement and Why Is It Important?” (Washington DC: 2010).

  18. Audrey Revere, “JCAHO National Patient Safety Goals for 2007,” Topics in Patient Safety 7, no. 1 (2007), VA National Center for Patient Safety.

  19. Coulter and Ellins, “Effectiveness of Strategies for Informing, Educating, and Involving Patients.”

  20. Amy D. Waterman et al., “Brief Report: Hospitalized Patients’ Attitudes About and Participation in Error Prevention,” Journal of General Internal Medicine 21, no. 4 (2006).

  21. M. McGuckin et al., “Evaluation of a Patient-Empowering Hand Hygiene Programme in the UK,” Journal of Hospital Infection 48, no. 3 (2001).

  22. Christopher Paul Duncan and Carol Dealey, “Patients’ Feelings About Hand Washing, MRSA Status and Patient Information,” British Journal of Nursing 16, no. 1 (2007).

  23. Monash Institute of Health Service Research, “Literature Review Regarding Patient Engagement in Patient Safety Initiatives,” 2008, http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Literature-Review-Regarding-Patient-Engagement-in-Patient-Safety-Initiatives.pdf.

  24. Maureen Maurer et al., “Guide to Parent and Family Engagement: Environmental Scan Report,” in AHRQ Publication No. 12-0042-EF (Rockville, MD: Agency for Healthcare Research and Quality, 2012).

  25. Maurer et al., “Guide to Parent and Family Engagement.”

  26. M. K. Paasche-Orlow et al., “The Prevalence of Limited Health Literacy,” Journal of General Internal Medicine 20, no. 2 (2005).

  27. Vikki Entwistle, Michelle M. Mello, and Troyen A. Brennan, “Advising Patients About Patient Safety: Current Initiatives Risk Shifting Responsibility,” Journal on Quality and Patient Safety 31, no. 9 (2005).

  28. National Patient Safety Foundation, “Health Literacy: Statistics at-a-Glance,” 2011, https://c.ymcdn.com/sites/www.npsf.org/resource/collection/9220B314-9666-40DA-89DA-9F46357530F1/AskMe3_Stats_English.pdf.

  29. Cecelia Conrath Doak, Leonard G. Doak, and Jane H. Root, “The Literacy Problem,” in Teaching Patients with Low Literacy Skills (Philadelphia: J. B. Lippincott Co., 1996).

  30. Irwin S. Kirsch et al., “Adult Literacy in America: A First Look at the Findings of the National Adult Literacy Survey,” ed. Office of Educational Research and Improvement (U.S. Department of Education, 2002).

  31. Paasche-Orlow et al., “The Prevalence of Limited Health Literacy.”

  32. Doak, Doak, and Root, “The Literacy Problem.”

  33. Maurer et al., “Guide to Parent and Family Engagement,” 2.

  34. Vikki Entwistle, “Nursing Shortages and Patient Safety Problems in the Hospital Care: Is Clinical Monitoring by Families Part of the Solution?” Health Expectations 7 (2004); Entwistle, Mello, and Brennan, “Advising Patients About Patient Safety.”

  35. G. B. LeFever, “Chasing Zero Events of Harm: An Urgent Call to Expand Safety Culture Work and Patient Engagement,” Nursing and Patient Care (February 2010), http://www.yoursls.com/ConnectingHospitals-Communities.pdf.

  36. M. Leonard, S. Graham, and D. Bonacum, “The Human Factor: The Critical Importance of Effective Teamwork and Communication in Providing Safe Care,” Quality and Safety in Health Care 13, no. Suppl. 1 (2004).

  37. J. Sorra et al., “Hospital Survey on Patient Safety Culture” (Rockville, MD: Agency for Healthcare Research and Quality, 2012).

  38. Ayako Okuyama, Cordula Wagner, and Bart Bijnen, “Speaking up for Patient Safety by Hospital-Based Health Care Professionals: A Literature Review,” BMC Health Services Research 14 (2014).

  39. M. J. Bittle and S. LaMarch, “Engaging the Patient as Observer to Promote Hand Hygiene Compliance in Ambulatory Care,” The Joint Commission Journal on Quality and Patient Safety 35, no. 10 (2009).

  40. Comment on the Joint Commission’s Center for Transforming Healthcare: The Joint Commission formed the Center for Transforming Healthcare in 2008 to solve healthcare’s most pressing issues. Eliminating healthcare-associated infections has been one of its primary initiatives (http://www.centerfortransforminghealthcare.org).

  41. Duhigg, The Power of Habit.

  Chapter 3

  1. Sanjaya Kumar, Fatal Care: Survive in the U.S. Health System (Minneapolis, MN: IGI Press, 2008).

  2. Infection Control Today, “Hospitals Pair Germ-Killing Robots with CDC Protocols to Protect against Ebola Virus,” Infection Control Today (2014), http://www.infectioncontroltoday.com/news/2014/10/hospitals-pair-germkilling-robots-with-cdc-protocols-to-protect-against-ebola-virus.aspx.

  3. G. B. LeFever, “Chasing Zero Events of Harm: An Urgent Call to Expand Safety Culture Work and Patient Engagement,” Nursing and Patient Care (February 2010), http://www.you
rsls.com/ConnectingHospitals-Communities.pdf.

  4. World Health Organization, WHO Guidelines on Hand Hygiene in Health Care: A Summary (Geneva, Switzerland: World Health Organization, 2009).

  5. K. L. Cummings, D. J. Anderson, and K. S. Kaye, “Hand Hygiene Noncompliance and the Cost of Hospital-Acquired Methicillin-Resistant Staphylococcus Aureus Infection,” Infection Control and Hospital Epidemiology 31, no. 4 (2010): 357–64.

  6. K. Sack, “A Hospital Hand-Washing Project to Save Lives and Money,” New York Times, September 10, 2009.

  7. Stephen Y. Liang, Daniel L. Theodoro, Jeremiah D. Schuur, and Jonas Marschall, “Infection Prevention in the Emergency Department,” Infectious Disease 64, no. 3 (2014): 299–313.

  8. Randi Hutter Epstein, Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank (New York: W. W. Norton and Company, 2010).

  9. C. R. Denham, P. Angood, D. Berwick, L. Binder, C. Clancy, J. Corrigan, and D. Hunt, “The Vital Link Department: Making Idealized Design a Reality,” Journal of Patient Safety 5, no. 4 (2009): 216–22.

  10. Charles R. Denham, Peter Angood, Don Berwick, Leah Binder, Carolyn M. Clancy, Janet M. Corrigan, and David Hunt, “Chasing Zero: Can Reality Meet the Rhetoric?” Journal of Patient Safety 5, no. 4 (2009): 216–22.

  11. Frances S. Margolin, “Getting to Zero: Reducing Rates of CLABSI in Community Hospitals” (2011), http://haifocus.com/leapfrog-audio-replay-getting-to-zero-reducing-rates-of-clabsi-in-community-hospitals/.

  12. Peter Pronovost, Dale Needham, Sean Berenholtz, David Sinopoli, Haitao Chu, Sara Cosgrove, Bryan Sexton et al., “An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU,” New England Journal of Medicine 355, no. 26 (2006): 2725–32.

  13. P. J. Pronovost and E. Vohr, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out (New York: Penquin Group, 2010).

  14. Peter Pronovost, Christine A. Goeschel, Elizabeth Colantuoni, Sam Watson, Lisa H. Lubomski, Sean M. Berenholtz, David A. Thompson et al., “Sustaining Reductions in Catheter Related Bloodstream Infections in Michigan Intensive Care Units: Observational Study,” BMJ: British Medical Journal 340 (2010): c309.