On day three of our Academy for Emerging Leaders in Patient Safety…the Doha Experience, Dr. Seth Krevat, AVP for Patient Safety at MedStar Health, led discussions on the importance of in-depth Event Reviews, Care for the Caregiver, and Fair and Just Culture approaches to preventable harm events. Seth shared the event review process used at MedStar Health which was designed by experts in patient safety, human factors engineering and non-healthcare industry resilience leaders. This event review process has been adopted by AHRQ and AHA/HRET, and has been incorporated into the upcoming CandOR Toolkit being released shortly to US hospitals.
The young learners engaged in deep discussions around Fair and Just Culture – the balance between safety science and personal accountability. This topic followed interactive learning the previous day on human factors and system/process breakdowns. Similar to challenges we have in the US, the culture in the Middle East blames the individual first without a thorough understanding of all the causal factors leading up to an unanticipated event. After Seth showed the video, Annie’s Story: How A Systems Approach Can Change Safety Culture, and shared other case examples demonstrating how a good event review can disclose system breakdowns versus individual culpability, the young leaders gained a new appreciation of effective error reduction strategies. In the short clip that follows one of our young leaders, so empowered by the short three days with us, explains how she used what she learned to try to change her parents point of view on patient harm:
The passion and commitment of these future leaders to patient safety was inspiring for our US faculty, as well as for the leaders from the numerous Qatar healthcare institutions that participated in our sessions. I have no doubt this next generation of caregivers will be the change agents needed to achieve zero preventable harm across the world. We have seen many examples of their work already.
It was exciting to be in Qatar working collaboratively with others who are committed to “Educating the Young” as a powerful vehicle for change. Next stop for the Academy for Emerging Leaders in Patient Safety…The Sydney Australia Experience!
Over the last few years, we have written about the vital importance of Care-for-the-Caregiver programs when unintended patient harm occurs from a medical error. As caregivers, the willingness to admit our humanness, as well as our ability to make an error, helps us reframe the recovery and learning process when these events tragically occur. All too often, we have turned away from our fellow colleagues, or worse, blamed them at a time when they needed our support the most. We all know of stories where good, caring healthcare professionals have taken their own lives after unintentionally harming a patient. As a profession, we need to do better.
I encourage everyone to read an outstanding two-page opinion piece in JAMA titled “What I Learned About Adverse Events From Captain Sully – It’s Not What You Think”. Written by Marjorie Podraza Steigler, a fellow anesthesiologist, the article should cause all of us to stop and rethink this important question. An emotional toll on physicians and nurses may occur even when no error was made, and the care team responded with precision during a major patient care crisis. As a cardiac anesthesiologist, I think of emergent, high-risk cases that went for hours, and while the outcome may have been good, the team was physically and emotionally drained afterwards. All of us, however, were usually expected to immediately return to the operating room for the next case often without time to process what had just occurred.
As Dr. Steigler correctly points out:
The contrast between the immediate removal from duty for those involved in the Miracle on the Hudson and the expectation that permeates our hospitals is stark. In both cases, the safe care of the next “customers,” whether they be travelers or patients, is at stake.
We have to do better for ourselves if we ever expect to do better for our patients.
For the last 18 months or so, we have been sending out our Monday morning “Good Catch” of the Week. Our initial email list included about 30 associate leaders, and it was a weekly email highlighting a story we had heard about through our Quality & Safety Directors across our health system. Our initial intent was to recognize caregivers at the front lines for all the great work they do every day. Through their mindfulness (sensing something wasn’t quite right) – and their actions (stopping the line), our patients were safer in our environment…and with the knowledge gained, we now had the ability to seek solutions to possible clinical care gaps. Both associate empowerment and recognition, along with greater knowledge about the health of our system, all are instrumental as we continue to seek high reliability at MedStar Health. An additional plus around our Good Catch celebrations is the Joy and Meaning we hope to inspire within our front line caregivers…something that is so badly needed in healthcare today.
And it’s working! Our Good Catch stories have become infectious. Over the course of the last 18 months, our email list has grown to almost 2,000 of our associates–a result of receiving many requests to, “please add me to the list”. Our Good Catch program has taken on a life of its own, and we no longer have to seek out stories from the front lines of care – they are sent proudly by many. Many of our entities also have a Good Catch program of their own in place, which adds a nice “local flavor” to the celebrations. It is truly inspiring to see.
But what has been even more amazing, is that people are now reaching out to us for more good catch stories. Stories that they can use as Safety Moments to start every one of our meetings! As a result, our last Good Catch Monday, put out by Seth Krevat, AVP of Safety, provided some tips on how to find and take note of all the safety moments around us. Seth’s recent email inspired Richard Corder, a fellow Telluride faculty and good friend/mentor, to pen the following after an unfortunate event in his kitchen. Richard’s story highlights the importance of the term “unconsciously competent” – doing certain tasks so often that we take the related risk involved for granted, and begin without thinking while multi-tasking, or with numerous distractions occurring around us. Pilots follow what is called “sterile cockpit” – no personal conversations or distractions during take-off and landing when the plane is below 10,000 feet so they stay focused on the task at hand even though they have done it thousands of times. In healthcare, there are many rote tasks related to the delivery of care and taking even the simplest of those for granted can result in harm to a patient or provider. Richard’s story (Re-learning the lessons of distractions and over-confidence) is well worth the read, and shows how even the simplest of kitchen tasks can present a risk when not staying mindful and in the moment.
As we have touched on previously, high reliability organizations are built upon a foundation with a just culture as the framework. That framework is comprised of a number of components, with incident reporting playing an integral role. Without a thorough understanding of a health system’s strengths and weaknesses achieving high reliability will be challenging, according to the experts. To better understand the areas of potential weakness, every unsafe condition, near miss or harm event needs to be reported and analyzed in order to find the place where, as James Reason advises, the holes in the swiss cheese are soon likely to line up, and cause greater harm. For those unfamiliar with Reason’s work, Bob Wachter MD provides good background information, describing him as the “intellectual father of the patient safety field” in his post, “James Reason and the foundation of patient safety” on KevinMD.
One reason given by healthcare providers for not reporting, is that they are unsure of what to report. As an organization moves into incident reporting as a system, it’s important to define expectations around what should be reported, and to convey the importance of reporting as well as the mechanics of how to generate a report. While definitions for unsafe conditions, near misses and patient harm may be subtly different from health system to health system, a “common formats” definition for patient safety terminology was developed by AHRQ to level the playing field. Those definitions related to our discussion are:
- Unsafe condition: Any circumstance that increases the probability of a patient safety event; includes a defective or deficient input to (or) environment of a care process that increases the risk of an unsafe act, care process failure or error, or patient safety event. An unsafe condition does not involve an identifiable patient.
- Near miss: An event that did not reach a patient. For example: discovery of a dispensing error by a nurse as part of the process of administering the medication to a patient (which if not discovered would have become an incident); discovery of a mislabeled specimen in a laboratory (which if not discovered might subsequently have resulted in an incident).
- Patient harm: Physical or psychological injury (including increased anxiety), inconvenience (such as prolonged treatment), monetary loss, and/or social impact, etc. suffered by a person.
Why should we report these incidents? Because every report submitted provides an opportunity to improve upon an aspect of patient care that could potentially cause greater harm in the future. High reliability organizations are mindful and working toward improvement every minute of every day. As such, they look for the opportunities to improve that these reports provide. It is important that everyone in the health system–from environmental services to CEO–understands they can (and should) play a role in improving patient care by submitting an incident report in real-time when they see, or are part of, any of the events mentioned above. Having everyone in the organization with a like mindset, increases the chance a potential harm will be caught before it reaches the patient. And by rewarding and celebrating those who submit reports providing that opportunity to improve a just culture is further solidified.