The Time is Now: ‘Culture of Safety’ Key to Preventing Errors

By Cathryn Domrose

When staff nurses at the University of California, San Francisco Medical Center recently attended a patient-safety class devoted to infection control, they listened to a mother whose child acquired a surgery-site staph infection while in the hospital for a biopsy. The mother talked about how some clinicians wouldn’t acknowledge that her child’s infection was caused by their care, how the child spent three weeks in the ICU, how many months later, the child and her family still dread driving by the hospital because of their terrible experience.

“For the nurses to hear that was very powerful” because it illustrated the harm clinicians can unknowingly do to patients when they don’t follow proper safety procedures, says Kathleen Burke, RN-BC, BSN, chair of the UCSF Patient Safety Fellows, a group of staff nurses devoted to patient-safety issues that puts on the “Stories From the Bedside” classes. Much of patient safety is about awareness, she says. “We’re not aware many errors are preventable. The general myth is still pervasive — that errors occur by negligent or uncaring health professionals, and of course that is not me.”

Culture of Safety
Ten years after the Institute of Medicine’s “To Err is Human” report concluded medical errors are mostly the fault of systems rather than individuals, patient-safety advocates, researchers, quality analysts and others are using scientific methods to determine why those systems continue to allow preventable medical errors to happen. What they are finding is although improvements in methods and technologies can be useful tools, the most important factors in improving patient safety remain the human ones — leadership, communication, teamwork, staff empowerment — which help create what patient-safety experts call “a culture of safety” with the patient at the center.

“Culture change is kind of the lubricant that allows patient-safety work to happen,” says Christine Goeschel, RN, MPA, MPS, ScD, director of patient safety and quality initiatives and manager of operations for the Johns Hopkins Quality and Safety Research Group at the Johns Hopkins School of Medicine in Baltimore, and founding executive director of the Michigan Health and Hospital Association Keystone Center, a patient-safety improvement group.

Preventable mistakes still kill about 100,000 people a year, according to consumer groups, despite national attention given to the issue since the IOM report attributed 98,000 U.S. deaths annually to preventable medical errors. Some believe the slight increase may be the result of better reporting, and the number of errors actually may have decreased somewhat. But most patient-safety experts say the healthcare industry has done a poor job of reducing preventable medical errors in hospitals and nursing homes.

“It probably is better reporting, but the public deserves better than that,” says Peter Pronovost, MD, PhD, medical director of the Center for Innovation in Quality Patient Care at the Johns Hopkins University School of Medicine, and author of “Safe Patients Smart Hospitals, How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out,” about his work with checklists and safety culture at Johns Hopkins and hospitals in Michigan. “We can send a ship to Mars. We can sequence the entire human genome with 99.9% accuracy. Surely we can reduce [preventable] errors.”

Evidence-Based Tools
Some progress has been made. By studying other industries such as aviation, research in the relatively new science of healthcare delivery has produced a number of evidence-based tools, including checklists for preventing infections, “time-outs” before a surgery and “no interruption zones” for nurses giving medications. New technologies include computerized physician-order entry systems, bar codes for patient and medication identification, safe pumps, electronic health records and computerized prompt systems.

Some studies show extraordinary results for these tools. Using a five-step checklist developed by Pronovost, ICUs in Michigan virtually eliminated central-line catheter infections and have continued to keep infection rates at near zero three years after the procedure first was adopted. The use of a surgical safety checklist developed by the World Health Organization decreased deaths and major postoperative complications by 36% in eight hospitals around the world, according to a New England Journal of Medicine study published last year. A recent study out of Brigham and Women’s Hospital in Boston found that a combination of bar-code technology and electronic medication administration records substantially reduced medication errors and essentially eliminated transcription errors.

Researchers for these projects say the new procedures and technologies work only when accompanied by efforts to improve the safety culture of the hospital, the involvement of the healthcare team and the collection of data to show clinicians the tools actually work. In Michigan, along with the checklist, Goeschel, Pronovost and their colleagues introduced the Comprehensive Unit-Based Safety Program, which included improving communication among clinicians; improving teamwork; engaging leadership; focusing on surveillance, monitoring and feedback; and using a patient-safety culture assessment. They are working to expand the project nationally.

The culture piece is often the most difficult part, Goeschel says. “If it was as easy as adapting the checklist, our work would be done.” Data collection and feedback are also important, she says. “Once clinicians begin to see success, it’s empowering and it feeds on itself.”

Before introducing bar codes, researchers at Brigham and Women’s studied workflow patterns to see how the technology could best help nurses give medications safely, says Carol Keohane, RN, BSN, program director for the Center for Patient Safety Research and Practice at Brigham and Women’s, and a co-author of the bar-code study. They tested the technology for potential barriers to adoption, finding nurses preferred the full screens of regular-size laptops to tablet computers. Researchers and nurse educators explained bar codes were an extra safety net to verify medication administration, not a replacement for nursing expertise or critical thinking.

But the greatest buy-in from nurses comes when the bar code prevents a potential error, Keohane says. “When you scan and get an alert and say, ‘I could have made a mistake,’ you’re a convert.”

Read the full article at Nurse.com, August 23, 2010