Book Excerpt: The Essential Guide for Patient Safety Officers

Note: The Essential Guide for Patient Safety Officers, copublished with the Institute for Healthcare Improvement (IHI), is a comprehensive and authoritative repository of essential knowledge on patient safety. An esteemed group of editors/authors— Allan Frankel, M.D., Terri Simmonds, R.N., CPHQ, Carol Haraden, Ph.D., and Michael Leonard, M.D.—has crafted content geared to help patient safety leaders create a culture of safety; plan, oversee, and implement new safety practices and improve safety-related management and operations.

Ms. Rodriguez is prepped in the preoperative area by Eileen Page, a registered nurse and 20-year veteran of the hospital. Per the organization’s protocol, Ms. Rodriguez is supposed to receive prophylactic antibiotics one hour before her surgery. Because it is approaching 45 minutes before Ms. Rodriguez’s scheduled surgical start time, Ms. Page is in a hurry to give the preoperative antibiotics. Busy with another patient as well, Ms. Page has dozens of procedural steps she must perform to ready both patients for surgery, and she inadvertently overlooks checking the medical record for allergies. Unfortunately, Ms. Rodriguez is allergic to certain antibiotics, including the ones that Ms. Page is about to administer. Buried in the many pages of the medical record is a note about a significant systemic reaction to antibiotics, but no one has noted Ms. Rodriguez’s allergies in a prominent place where Ms. Page could easily be reminded.

Because she is in a hurry, Ms. Page tries quickly to explain to Ms. Rodriguez what she is doing. Ms. Rodriguez is from Venezuela and does not speak English well. Ms. Page does not speak Spanish, so communication is sketchy at best. The Spanish-speaking nurse on staff is busy attending to another patient, and Ms. Page is trying to move Ms. Rodriguez quickly into surgery so the surgery schedule will not be too adversely impacted. Organization leadership has repeatedly stressed to frontline staff the importance of adhering to the surgery schedule— cases must start on time. In fact, management closely tracks the percentage of cases that start on time and continually pushes to improve it.

As Ms. Page begins to administer the antibiotics, Ms. Rodriguez becomes agitated because of her lack of ability to communicate clearly. Although Ms. Page notices the agitation, she assumes Ms. Rodriguez is just nervous before her surgery. Approximately 45 minutes after receiving the antibiotics, Ms. Rodriguez is brought into the operating room (OR). The surgeon is anxious to get started and very curtly calls the OR team together to begin surgery. As the surgery begins, the OR staff notices that Ms. Rodriguez’s vital signs are quite abnormal, and she appears to be in respiratory distress. The team is unclear as to what is happening, and the surgeon barks out an order to one of the circulating nurses to quickly check the medical record for any clues. The OR team tries to stabilize Ms. Rodriguez, but she suffers cardiovascular collapse, is ultimately resuscitated, but suffers significant severe neurologic injury.

After quickly reviewing the medical record, the team realizes the nature of the problem. Ms. Page is devastated. The media swarms onto the campus of the medical center, asking many difficult questions that the leaders of the institution are unable to answer to their satisfaction. Ms. Rodriguez’s family is kept in the dark about what really happened to their loved one, so they retain an attorney to represent them. The public is outraged by this tragic mistake and start demanding that the hospital do something to prevent this kind of event in the future. Leadership in the organization begins to look for someone to blame for the incident, and Ms. Page seems like a good candidate. Eventually, hospital leadership goes before the press and public and commit to eliminating medical errors in their facility and improving safety. They hire a consultant, launch some safety initiatives that target medication errors, and feel confident their work is making a difference. However, the root causes of the event that occurred in the OR are still present in the organization: lack of communication, lack of teamwork, lack of patient involvement, lack of reliable processes, lack of organizational emphasis on safety and reliability, and the inability of the organization to continuously learn from its mistakes. While the implemented safety initiatives may improve medication safety in the organization for a short time, they serve only as a Band-Aid for a deeper, more long-term problem.

What if this operating room scenario or one like it occurred in your organization? Would the response have been the same? Does your organization and its senior leadership value and commit to a culture of safety? Reliable systems? Teamwork and communication? Is the accountability system in your organization structured to protect the hardworking nurse like Ms. Page, who inadvertently makes a mistake because of a series of system errors? Or is it designed to identify fault and place blame? When errors do occur, does your organization have a systematic approach to responding and learning from them? Does your organization have an open and honest disclosure process? Are patients involved in their care? Do they have a voice within the organization? If your answers to any of these questions are “no,” you are not alone. However, you are also nowhere near where you need to be in providing safe and reliable health care.

All Work and not Enough Gain
Since the Institute of Medicine’s 1999 landmark report on medical error,1 many health care organizations have focused on reducing medical errors and enhancing the safety of patients. Despite this focus, the number of medical errors occurring in the United States has not appreciably changed. While intentions are good, there is often a substantial gap between the safe and reliable care we know to be effective and the current care that is provided. As a whole, health care organizations are still experiencing error at an unacceptable rate and are continuing to harm people in repetitive and predictable ways.

While there have been some very successful individual efforts to address the issue of safety, much of the work has been fragmented or focused on specific small areas. These efforts have shown some short-term success, but long-term improvement has remained elusive. The creation of patient safety officers within health care is an important step on this journey.

Addressing the Root of the Problem
The primary reason for the lack of progress is that organizations are not addressing the roots of the safety problem. Yes, decreasing error is important, but it cannot happen without an environment that supports a systematic approach to creating and maintaining reliable processes and continuous learning. In other words, before an organization can realize sustained improvement, it must commit to designing reliable processes that prevent or mitigate the effects of human error and establish a culture where teamwork thrives, people talk about mistakes, and everyone is committed to learning and improvement. Once an organization achieves an environment of reliability and continuous learning, then patient safety becomes a property or characteristic of the organization and, by definition, the organization starts to reduce errors.

Making Safety an Organizationwide Imperative
So how do you achieve an environment where reliable processes exist and continuous learning is an intrinsic value? It doesn’t happen by just telling employees to try harder to be safe. It requires a systematic approach that addresses the fundamental ways in which providers interact and provide care. Such a systematic approach involves four critical components²:
1. A strategy, which focuses on reliability and continuous learning. This strategy represents an organization’s basic values and vision as well as its goals.
2. A structure, which consistently supports the strategy and helps integrate it into the accepted way of doing business. Such a structure builds the appropriate framework, designates the appropriate resources, and defines the reporting relationships that effectively support the strategy.
3. An environment or culture that supports the structure and ensures the proper execution of deliverable outcomes to meet strategic objectives, such as reduced error and enhanced patient safety.
4. Clear outcomes and associated metrics that are visible, both internally to the people doing the work and externally to the market and the public. These outcomes and metrics help drive consistent improvement within the organization.

The Essential Guide for Patient Safety Officers provides a road map for organizations to create the necessary strategy, structure, environment, and metrics that focus on reliability and improve patient safety. Based on the Institute for Healthcare Improvement’s Patient Safety Officer Course—a synthesis of patient safety experts’ collective experience— each brief, easy-to-digest chapter focuses on a different stop along the map, as follows:
• The Role of Leadership
• Safety Culture
• Accountability
• Reliability and Resilience
• Systemic Flow of Information
• Teamwork and Communication
• Direct Observation and Feedback
• Disclosure
• Patient Involvement
• Technology
• Measurement Strategies
• Process Improvement Methods
• Effective Implementation Strategies

Despite the specificity of its title, this book is designed to help anyone in an organization improve the safety of care provided to patients from the patient safety officer to frontline staff who are charged with and/or interested in improving the provision of care. Even if your organization does not have a patient safety officer per se, you can benefit from this publication as it discusses the critical steps involved in enhancing patient safety throughout an organization and ensuring the reliability of care. By the time you finish reading this book, you should have a clear understanding of what is involved in creating and sustaining a culture of safe and reliable care. You will be armed with tips and tools to apply to your own organization and examples from other organizations that have engaged in these efforts. The concepts discussed within this book may be simple in theory, but they can be quite challenging to implement without complete organizational support of a strategic approach to improvement. It takes a commitment from all levels to systematically drive this work and achieve success.

However, by incorporating the different elements discussed in this book into everyday work, organizations can take a step toward reliability, learn from mistakes, and continuously improve, enhance, and achieve patient safety. It is important to note that while the overall goal of safe and reliable care may seem somewhat daunting, there is a great deal of low-hanging fruit, and committed individuals can and do make a huge difference in how we care for patients.

References
1. Kohn L., et al.: To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine of the National Acadamies, Nov. 1, 1999.
2. Frankel A.S., Leonard M.W., Denham C.R.: Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability. Health Serv Res 41:1690–1709, 2006.