March 2-8, 2014 is National Patient Safety Awareness Week, an annual education and awareness campaign for health care safety. In 2013, the University of Vermont Medical Center earned #1 ranking in providing safe patient care in the national University HealthSystem Consortium (UHC) Quality and Accountability Study.
In the early 1980s when I graduated from Nursing school, “patient safety” as we know it today did not exist. Of course, we wanted our patients to receive high quality, safe care, but there was no systemic structure or method for how to get there. “Mistakes” were to be feared and (hopefully) avoided. If you were a “good” nurse or doctor and were vigilant at all times, (and if you were lucky) any mistakes that you did make would not seriously harm a patient. Those who made mistakes were often fired, disciplined or shamed as a warning to their peers. Be careful…”you better not make a mistake” was the implicit message. And we took that message to heart.
Fast forward 30 years and we’ve come a long way in the field of patient safety. There is a new field of knowledge that has developed over these decades about how and why human errors occur and what can be done to reduce or eliminate harm to patients.
The book “Human Error” by physician James Reason describes how complex systems and processes can fail. Although we strive to prevent error, when humans are involved, complete error prevention is impossible; however, “human factors,” such as fatigue, memory, distraction, and cognitive biases can be engineered out of the system in many cases. One example comes from the world of automotive safety. At one time, cars would lurch forward or backwards accidentally if the gear was not completely engaged in “Park.” This caused many accidents and injuries. Note now that one must apply pressure to the brake before one is able to move the gear out of “Park.” The auto manufacturers recognized the possibility of driver error and engineered this mistake out of the system. This has prevented the inadvertent forward or backward motion that caused these injuries. The lesson? We must design systems that anticipate human failure and develop strategic redundancies and safety measures to reduce or mitigate harm.
Similarly, in health care, we can also change the way that care is provided to avoid or minimize risk. Consider just a few of the processes we have in place at the UVM Medical Center:
- Patient controlled analgesia (PCA) pumps have a lock out timing feature that does not allow patients to press the dosing mechanism too many times;
- We perform pre-procedure “briefs” to make sure that everyone on the team has confirmed the right patient, right procedure, that the right equipment is available, and that everyone knows what is supposed to occur and what safety issues to look for;
- We use checklists to ensure that the key components of a process are met, each and every time. By doing this, we have greatly reduced and in some cases, completely eliminated errors and health care related harm, such as hospital acquired infections;
- There is now computerized physician order entry, which eliminates legibility problems; and
- Tests and laboratory results are now immediately available to care providers through the electronic health record.
Perhaps the most important lesson learned in the past 30 years, is that punishing or shaming people for the failures designed into the system is neither productive nor helpful, and only serves to push discovery of these failures underground until it is too late, and patients are harmed. A positive culture of safety, where people understand how systems and processes can be designed to fail, and where they feel safe reporting adverse events, system failures and near misses without fear of retaliation, helps to identify latent failures before a patient is impacted. at the UVM Medical Center:
- We measure our culture of safety regularly, and our results have consistently shown a highly positive culture (positive is best) compared to national benchmarks of other Academic Medical Centers.
- We reward and encourage the reporting of problems so that we can ensure the safest possible care for our patients.
We have all accessed the health care system at some point in our lives, and we have friends and family who have needed health care. As the Director of Patient Safety &Advocacy, and as a nurse, it has been wonderful to observe the positive changes in patient safety over my career. I am happy to be able to work in an environment where patient safety is the first priority, and with colleagues who genuinely care and desire to improve how health services are provided. In celebration of National Patient Safety Awareness Week, we salute the thousands of employees and health care providers who take care of us and put patient safety first every day.
Lori Notowitz, RN, MJ, CPPS, is Director of Patient Safety & Advocacy at the University of Vermont Medical Center, part of the James M. Jeffords Institute for Quality and Operational Effectiveness.