Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

High Reliability Hospitals: Now We're Chasing Zero (Part 1 of 2)

6/2/2015 12:18:49 PM | 3 comments

Hospitals are dangerous places. Sure, a lot of great care occurs under their roofs. But let’s face it, even the most skillful, compassionate healthcare professionals sometimes make mistakes that cause harm.
 
Consider catheter-associated urinary tract infections, central line infections, medication errors and medical errors. We used to say that these things were unavoidable or "known complications," but as our industry changes, that mindset is being challenged. Consumers and regulators are sending a clear message that one preventable injury, infection or death is too many.
 
Hospitals are now chasing the goals of zero infections, zero medication errors, zero falls and zero wrong-site surgeries. And to succeed, they need Healthcare providers to join the pursuit.


Protecting Us From Ourselves


Why do healthcare providers make mistakes? Well, as much as we hate to admit it, we're human.
 
We can’t be perfect all the time. Sometimes we get distracted, space out, have too many balls in the air, don’t think through consequences or get interrupted. It can happen to the best of us at any moment — even during a task we have done over and over.
 
Fortunately, we live in a country where human failure is taken for granted. In fact, many engineers, managers, psychologists and lawyers make careers out of identifying risk and figuring out ways to mitigate it.
 
Take this scenario. I actually saw someone at a gas station pull away from the pump with the hose still in the gas tank. Much to my amazement, there was no explosion, no fire, no gas pouring out of the pump. Why? Because someone had thought ahead and actually designed the hose to break at a coupling that automatically shuts down the pump when it separates. This is the same reason guns have safeties, pool gates latch behind you and cars won't start unless your foot is on the brake.
 
Now even without these basic product safety measures, the risk of something happening is pretty small. In the worst-case scenario, only one or two people would be affected. Still, manufacturers and regulators have decided that its worth the cost and effort to eliminate even these small risks.


High Stakes Safeguards


Of course, it takes more than a circuit breaker or automatic gate latch to address safety issues in healthcare. Ours is a hugely complex industry with infinite opportunities for systemic and individual error. Reducing adverse events to zero may sound like a nice idea, but is it really possible?
 
To answer that question, let's take a look at some other complex industries.
 
Our hospital is currently working with a healthcare safety consultant at HPI (Health Performance Improvement) who started his career as a nuclear engineer. Now there's a field where a small error can have grave consequences. And nuclear power plants have a scary history. The Three Mile Island plant narrowly averted disaster in 1979. Radioactive releases during the 1986 Chernobyl disaster caused 28 deaths from acute radiation sickness and an estimated 6,000 cases of thyroid cancer.
 
But over the past few decades, nuclear power has transformed itself into a highly reliable industry. In 1989, US nuclear plants experienced 0.9 "significant events" a year. By 2009, that number had dropped to virtually zero (0.02), thanks to advances in safety and preparedness.
 
On top of that, did you know that most of the world's nuclear reactors aren't on land? The United States has about one hundred reactors at sea powering ships, aircraft carriers and submarines. And believe it or not, the US Nuclear Navy has a perfect reactor safety record — 5,400 reactor years without a single accident. The systems are so standardized and redundant, they can be safely operated by crewmembers in their teens and early twenties.
 
Aviation is another example of a highly reliable industry. According to a report by Boeing, in 1959, there were nearly 40 fatal accidents per million commercial flight departures from the United States and Canada. But the fatal accident rate is now less than 1 in a million, thanks to improvements in safety.


Count On Us?


Aviation and nuclear power are highly complex industries that not only fixed their risk and error issues but maintained those successes. In other words, they have become high reliability organizations (HROs).
 
As defined by Karl E. Weick and Kathleen M. Sutcliffe in their book Managing the Unexpected, HROs are organizations that operate under very trying conditions, yet manage to have fewer than their share of accidents. They do this by:
  • Being fanatics for safety
  • Making safety part of their DNA
  • Anticipating potential errors
  • Making system changes
  • Tracking results
There's no doubt that hospitals and health systems operate under very trying conditions. But can we say that we have done all we can to prevent errors?
 
In my opinion, compared to other complex industries, we have fallen short. A 1999 Institute of Medicine report estimated that preventable medical errors kill 44,000 to 98,000 Americans each year, which would put us in the same risk category as mountaineering and bungee jumping.
 
On the upside, many hospitals responded to the report by implementing safety measures:
  • "Do not use" abbreviation list
  • Tall Man lettering for medications
  • Different bottles for different liquid medication concentrations
  • Site marking before surgery
  • Medication read backs
  • Pre-procedure "time outs"
  • Protocols
  • Checklists
  • Mandated RN patient rounding
Why do we have these procedures? Because historically, real errors have occurred in these areas. Health care providers have surgically removed the wrong kidney, caused central line infections and injected patients with highly concentrated heparin.
 
Unfortunately, that hasn't stopped healthcare professionals from pushing back. Back when I was chief of staff at our hospital, I heard the full litany of protests against these "excessive" safety measures:
  • We know medicine better than the person who made that rule.
  • These things don't happen at our hospital.
  • That's never happened to me.
  • Some errors can't be prevented.
  • My patients are sicker, so they will have poorer outcomes. 
My response: errors are only rare if they don’t happen to you. These precautions are a bit like the coupling on the gasoline hose. They may seem like overkill. But if you could prevent harm to yourself, a friend or loved one, wouldn’t you want to do that?


A Choice for Change


Even if we are willing to accept a little risk as professionals, it doesn't matter. Our patients want zero errors, and the government has listened to them. Our entire industry is now "chasing zero" adverse events. We're headed down the same path airlines and nuclear power plants took decades ago.
 
To truly strive for zero medical errors takes more than just organizational and cultural change. Each individual provider must commit to changing his or her behavior. We all need to look around, identify risks and do what we can to mitigate them. We need to be actively involved in our hospital’s quality and safety initiatives, and we need to hold ourselves and our colleagues accountable to abiding by those recommendations.
 
In my next post, I'll share a key strategy that each of us can use to make our practice safer.

[Image credit: "ICU Critical Care 1" by Calleamanecer licensed under CC BY-SA 3.0]


Comments
Shaun Partlow
Great article, Dave! The comparisons are terrific: extremely high risk industries doing extremely well. I think an important point is that we are not expecting each provider to never make a mistake, but to commit to the systems and checks that will help catch the inevitable mistakes that all humans will make. The burden of zero errors doesn't rest on our individual but rather our collective shoulders as healthcare providers. We are all essential to the effort.
6/4/2015 4:19:07 PM

Jon Brummond
"Our patients want zero errors." Nicely stated. CEP America is such a patient centric organization that this resonates well within minds and hearts of our team!
Looking forward to part 2. Thanks for contributing.
6/3/2015 1:52:27 PM

Jeff Bass
Great article Dave! This is especially true for the ED, the most chaotic place in any hospital. Given the unpredicatable boluses of critically ill patients, communication issues that commonly occur and virtually constant interruptions the providers face, the number of small errors that occur every shift are truly scary. Every so often in virtually every hospital there's a "perfect storm" of events that leads to a catastrophic patient outcome. Through thoughtful, collaborative planning, these can and need to be eliminated. If the nuclear power and airline industries can do it, we can too. I look foward to reading your next post.
6/3/2015 12:09:16 PM