A Blue Christmas

The message inside the card reads, "Wishing you Christmas peace."

Some things just don't make sense. 

Elvis-as-messiah is one of them. And why a pharmacist will spend Christmas behind bars this year for an on-the-job error is another.

You can read more about Eric Cropp and the circumstances behind the tragic death of a toddler here.

Eric's address in the Cuyahoga County, Ohio jail appears at the bottom of the linked article. I'll be sending him one of the Elvis Christmas cards. There are 17 others in the box. I'll be happy to send one on your behalf, too.

These are a few of my favorite things.....

That's what Julie Andrews sang in the Sound of Music.

But I found them set to a different tune in a patient safety video created by nurse leaders who are DNP candidates. Thanks to Marie Duffy, Nancy Ramos, Cynthia Robotti, Rosita Rodriguez, and Sheryl Slonim for producing this excellent resource!

Grand Rounds at Charlotte's Web

Welcome to this holiday edition of Grand Rounds! It's the time of year when friends and family gather, when stories are told and memories are made. But the winter weather and short days here in the northern hemisphere seem to prompt brevity in our everyday comings and goings. It seems like the right time to combine storytelling and brevity and channel Charlotte, one of the most masterful storytellers I met during a childhood spent with my nose in a book.

In keeping with Charlotte's knack for saying what she meant and meaning what she said succinctly, I've categorized this week's submissions using six words that describe quality healthcare. (They're borrowed--in ways I suspect would make Templeton the Rat proud--from the Institute of Medicine's report Crossing the Quality Chasm.) This week participants were asked to submit one word describing the inspiration or take-away lesson for their post, and you'll find their words woven into today's Grand Rounds.

I hope you enjoy the tale. And do take the opportunity this holiday season to revisit Charlotte's Web. Better yet, share it with the next generation. As we seek solutions to the vexing issues healthcare bloggers wrote about for this edition, we'll be needing new words, spun by young people whose imaginations are ignited.

The word used by the authors of Crossing the Quality Chasm to say that patients should not be injured from care intended to help them.

Last week The Blog of the Interdisciplinary Nursing Quality Research Initiative completed an ambitious commemorative series marking the 10th anniversary of To Err is Human. Since Florence dot com is, first and foremost, a real-time patient safety primer, I'm going to carefully letter my chosen word here: LEARN. And tell you to click on this link to access INQRI's lovely collection of stories, recollections, and sage advice.

Care does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic means.

Dr. Rich gets to the meat of the matter in  Let Us Shun The Obese this Holiday Season. Dr. Rich's heart of darkness post (key word: demonization) could have fit nicely in many dimensions of care, patient-centered and effective sprung to mind. But his astute observation that obesity is often rooted in genetics makes it fit best here.

In The Users' Guide to the Health Reform Galaxy, Bruce Siegel stays on message with his word: equity. But read this post to learn why an insider believes minority groups could lose ground if health reform is not "done right." Louise from the Colorado Health Insurance Insider says the word is flaws and writes Why Health Care Reform is Important.

Care based on scientific knowledge should be provided to all who could benefit and not provided to those not likely to benefit (avoiding underuse and overuse, respectively).

Amy Romano, CNM gets a blue ribbon in this category for maximin, a word I didn't know and one that would surely delight Charlotte. Amy wisely included a vintage PubMed link explaining her word, and she articulates her position in What SUVs Can Teach Us About Maternity Care. Paul Auerbach discusses The Canadian C-Spine Rule, with a take-away word of algorithm.  Allergy Notes offers up "allergy" as an index word for the post describing the difference between food sensitization and food allergy.

Rounding out this dimension of quality healthcare are those who prompt us to pay attention to the quality and accessibility of  high end data. Eve Harris offers transparency as the take-away lesson in Asking Dr. Science. Walter Jessen at Medpedia, an innovative 2.0 health information community, uses "reliable" to describe Medpedia Now Includes News & Analysis, Alerts, Q&A. And over at Clinical Cases and Images - Blog, we're reminded that it's also helpful to think. And rewarded with a thoughtful post, Medical Textbooks and Atlases Searchable on Google Books.

Care is provided in ways that are respectful of and responsive to individual patient preferences, needs, and values. It ensures that patient values guide all clinical decisions.

The ACP Internist offers Doctors, Ditch the Tie and Coat, an interesting piece about appearance (how patients' perceptions of providers are shaped by both culture and the providers' choice of attire). I found another new Charlotte-worthy word reading this post: zoris. (Check out the post to learn what it means if it's new to you, too.)

Laurie Edwards says the relativity factor is confounding when people with chronic diseases go about Learning to be a Primary Care Patient. Amy Tenderich winds up in the middle here, too, a welcome place according to her Wayback Wednesday post Oh, Glorious Middle. And Rachel's simply titled post is For Now. But the word she sent along, patience, may say even more about what patient-centered care really entails.

Jacqueline at Laika's MedLibLog captures the arachnoid spirit, giving her post a one word title: empathy. The post shows how much we long for care that considers more about who we are than our "chief complaint" often reveals. If Jacqueline had been in the mood to spin longer, she could have called this post, "What comes around, goes around!"

Developmentally appropriate care may mean calling on the healing power of friendship, something Nancy Brown points out in Helping Friends Who are Stressed and Depressed. In another part of the village, Barbara Kivowitz cautions that assumptions are not always helpful in Seven Myths about Couples and Illness. And Will Meek says the word is forgiveness and writes about it in How to Forgive.

One of the things I like best about the IOM's six dimensions of care is this: stakeholders don't always wind up tangled in their own little bitty egg sacs. Lock Up Doc offers the word transparency to explain her position on Should Patients With Borderline Personality Disorder Be Told Their Diagnosis? (It's a stance that also earns her a place in the coveted "patient-centered" category.) Curiosity earns The Happy Hospitalist a place here, too. (And his post Gynecological Exams: Best Done By Male or Female Gynecologists earns another label: funny.)

Dr Charles gives a nod to resilience in his post Hypochondriachal Heroism. And child psychiatrist An Ang Zhang explains something that makes healthcare delivery a challenge: Lying people. She says more in The Smartest Lie: Lord Winston; Super Doctors & The Dark Side. But At How to Cope with Pain, the word is contest! Visit for a holiday-inspired change of pace and see what's cooking! (Spoiler alert: It's not pork.)

The need to reduce waits and sometimes harmful delays for both those who receive and those who give care.

Kim, a future nursing student, writes revisiting my hospital stay. Although she sent patience along as her take-away, I've chosen to place her post here because omissions count in quality measures. Rats!

Harry Stern at InsureBlog is worrying about supply and demand, too. His post, More (Un?)Intended Consequence, projects doctor shortages and backs up rather glum predictions with data from the Association of American Medical Colleges. ACP Hospitalist echoes the concern, with a call-to-action word: need. The post is New York survey shows dire need for hospitalists, internists.  I'll take this opportunity to weave in a bit of Cavatican-style cheer: mid-levels.

  Avoiding waste (of equipment, supplies, ideas, and energy).

At Shoot Up or Put Up, Tim's NHS pharmacist guest blogs with Diabetics - Blight of GPs; Milk Cows of Pharmacists, explaining why people with diabetes should engage their pharmacists. (He gets a blue ribbon for including a farm animal in the post title.) And a wry, trans-continental laugh for his take-away word: Pharma-conomics. Dr. Wes offers a one-word take-away to describe a mixed blessing: patient-provider e-mail. And he articulates both "added value" and "be careful" features of this mode in The Inefficiency of Medical E-Mail.
 
Jessica Otte explains how hard it is sleep while completing an obstetrical rotation in No electric sheep for me: Sleep is fragmented. Medical residents and how much sleep they get impacts the efficiency of individual physicians and the system that depends upon them. Her word is delusion. (I think it's meant to describe her current sleep-impaired state. But the word may also describe conventional wisdom that allowed residents' hours to remain relatively unchecked in the latter part of the 20th century.)
 
Over at the Healthcare Business Blog, David Williams says Atul Gawande is too optimistic about healthcare cost control when he advances the idea that the future of healthcare reform may lie in the county extension office. Williams is serious: his take-away word is pessimism. Marya Zilberberg calls out Gawande for another reason: shortsightedness. It's explained in her post Can US agriculture reform inform the healthcare debate? She offers thoughtfulness as her word.
 
Joseph Kim's one word is "leaving," a topic that inspired his post, Should You Leave Clinical Medicine? Finally, Jolie Bookspan offers appreciation at this time of year, with some special "academy" awards.
 
Correction to information for the next edition of Grand Rounds! It will be hosted next week, 12/22 by Nancy Brown of Teen Health 411. Nancy will accept submissions (to brownn at pamfri dot org) until Sunday, 12/20/09 at midnight. The theme is "coming together."


Note: The descriptors of the IOM's Six Dimensions of Care are reproduced from pages 5 & 6 of the Executive Summary, Crossing the Quality Chasm.

Take a Break from Hooking that Ugly Rug

My daughter hears with a cochlear implant. My 17 year old son, born with a digestive system problem that would have been lethal 50 years before his birth, now referees his dad's hockey games. Thanks to a heart-lung transplant, my first cousin lived to see her son grow from age 2 to age 12. Aggressive medical and surgical management of heart disease has enabled my dad to live beyond, by many years, the age when heart disease claimed the lives of his father and older brothers.

I think my family is probably a lot like yours. We're full of people who are the beneficiaries of medically-mediated miracles. When I visualize what modern medicine is capable of, the image is profound, mature, purposeful. It pulls from the best of what humans--energies harnessed and God-given talents extended on behalf of others--can do. Maybe it looks like this:

In the day to day business of healthcare, though, the challenge of engineering a system where safe, effective, and accessible care is realized can flummox mere mortals.

Don Berwick talked about the imperative of seeing the big picture earlier this week at IHI's National Forum. (I didn't attend this year, but benefitted from the summary Paul Levy shared on his blog.) If you didn't hear Berwick's words, Levy's post is worth a read.

The processes we use to make things come alive may work best when we break them into little bitty steps. But it's worth thinking about what it is you're trying to create and how you paint that picture for those whose efforts are integral to the success of the improvement efforts undertaken. Most professionals I know won't line up to see--let alone help craft--something that's supposed to come out like this:

When engineering quality measures, invest in front line clinicians. Engage them. Celebrate what they already do well. They're not all Michangelos. But few will be inspired to contribute by what's found in the craft aisle at Walmart.

It's also worth remembering that what's produced is going to be displayed in forums more like juried art shows than grandma's frig. So go on, take a break from hooking that ugly rug.

Grand Rounds in a Word

This week in Orlando, the Institute for Healthcare Improvement (IHI) is hosting their annual conference, one built upon a single well-chosen word: Simplify. I'll be hosting Grand Rounds here next Tuesday, 12/15 and thought we'd continue the tradition of saying what we mean and meaning what we say in a word.

You're invited to share what's on your mind about any healthcare-related topic important to you. Just send the name of your post and a link to blynnolson at gmail. The only thing you have to do to ensure your post will be included is this: Pull out ONE word that explains what motivated your post or describes the "take-away" lesson you want readers to remember and send it along with your submission. I'll do the rest!

Looking forward to receiving "the word." Please submit by 12/13/09 at midnight EST.

Who are these people? I don't always know but I'm lucky they're here.

Today is my birthday! And thanks to Facebook and other social media means, I'm able to be connected with people I know, once knew, and am getting to know! This is a blessing I am able to enjoy *virtually* every day! The diversity of people and experiences that make my life rich make me think--in very specific ways-- about precisely who is out there and what the challenges to making healthcare safe, effective, efficient, timely, equitable, and patient-centered really are.  

Here's something that made me smile last week, reprinted with permission from my cousin's Facebook page: 

Nick: "What's this?" 

Dad: "It's a pamphlet that tells you all about the flu shot you just got. You can read it if you want." 

Nick: *reads briefly, then BIG eyes* "I'M GONNA GET PREGNANT?????!!!!"

Thanks Ant and Nick! You left a great reminder that the toughest topics begin with basic steps to help people--all people--understand that when it comes to healthcare, patients are the ones with the biggest dog in the fight!

The Building Blocks of Better Care, 10 Years In the Making

This post is being cross-published today as part of The Blog of the Interdisciplinary Nursing Quality Research Initiative's commemoration of the 10th anniversary of To Err is Human.  You can find this contribution and other posts in two week series here.

Shortly after the second IOM report Crossing the Quality Chasm was published in 2001, Don Berwick authored a "users manual," a short document that clearly identified four broad stakeholder interests: the experience of patients; the functioning of the units where care is provided; the larger organizations in which direct care units reside; and the forces (policy, payment, regulatory, accreditation) that shape the performance of these organizations. Berwick described the model as necessarily hierarchical with the experience of the patient on top and other interests aligned to improve the health and functioning of the patients.

Berwick was probably wise to suggest that we begin crossing the quality chasm by holding on to the hierarchy. After all, no one understands hierarchies better than those who give and receive healthcare. By turning the hierarchy upside down, Berwick gave it a disruptive twist, one that helped re-establish the primacy of the care experience (and the outcomes attained) to the business of healthcare.

But I think Berwick was on to something better when he talked about the patient's experience being "true north." It's a construct that acknowledges the importance of the patient experience while seating all stakeholders around a common cause. 

The image of all stakeholders sharing space at the table works for me, especially since a decade's worth of study of system design and performance-shaping factors is dismantling the notion that strict hierarchies serve the interests of safety.

Ten years ago, the relationship between safety and strict deference to hierarchies—and other "soft" markers of dynamics that shape human performance—was not appreciated.  Cooperation, civility, and effective teamwork were seen as "nice to have's," the kind of behavior leaders might foster using sources like All I Really Need to Know I Learned in Kindergarten. Largely seen as social lubricants, behavior-based risk reduction strategies were given low priority in an increasingly technical healthcare domain.

A decade of studying what actually makes high-consequence industries reliable has sent healthcare stakeholders back to some foundational behavior-based learning. It turns out that things like speaking clearly, repeating words to be certain they have been understood; taking turns; using "inside" voices; and getting plenty of rest matter when individuals rely on complex processes to deliver intended outcomes. (Even "time-outs" have made a comeback!)

A series of recognizable standards and expectations are now visible on the frontlines of care. The Joint Commission’s National Patient Safety Goals is the most readily identifiable. But even more important to further progress are the larger studies and best practice recommendations linking elements of organizational culture to improvements in patient safety. Measures that support these relationships are plentiful, easy to locate, and increasingly integrated into forces that shape the performance of organizations.

The emergence of patient safety as a distinct discipline means the study of safety-sensitive processes and measures in healthcare now rests upon a conceptual framework, one that allows stakeholders to understand the science informing compliance measures in a way not possible before To Err is Human. We're poised to know, with increasing precision, not only who should be at the table but if what's being served is any good. 

Ten years spent building a table that so much rests upon is probably not too long. 

Glad you're here but there are other interesting places to visit, too!

The Tuesday redirect I normally reserve for Grand Rounds is being shared this week. This signifies a warm endorsement of the INQRI blog which today launched a 10 day series commemorating the 10th anniversary of the IOM report To Err is Human. But it doesn't mean that you shouldn't visit Health Technology News (where a good laugh is in store for those who remember Seinfeld & Co's patient adventures).

I've been surprised that the topic of patient safety--measures to prevent inadvertent harm to people who seek care--has received so little mainstream media attention in this very long season of talk about healthcare and reform. The INQRI To Err is Human series is a great place to hear how patient safety intention and outcome are converging, with some of the patient safety advocates who have led the charge taking time out to assess progress.

Check out INQRI in the coming days. There's something for everyone. (Florence herself is learning new things there!)

Thanks for speaking up

When I give talks about patient safety, I usually include a slide called, "Why Pilots Won't Nurse." It's an attention getter, one that draws smiles and sometimes fosters an "a-ha" moment for students, seasoned clinicians, and administrators.

I think that pilots won't nurse because, as a group, pilots are knowledgeble enough to reject systems that lack sufficient barriers, redundancies, and opportunities to uncover and rectify potentially lethal errors that have been set in motion. Commericial aviation isn't fool-proof, but the industry's 1 in 6 million crash rate shows what can be accomplished in high stakes domains when adequate barriers, redundancies, and recovery ops are in place.

I could add another slide: why pilots don't practice pharmacy. And there's no better place to read why than Bob Wachter's thanksgiving day post about the tragic case in Ohio, one in which a little girl lost her life, a family dissolved, and a pharmacist went to jail. 

Late last summer, Mike Cohen, the president of the Institute for Safe Medication Practices, published An Injustice Has Been Done about what happened to pharmacist Eric Cropp in the aftermath of little Emily Jerry's death. Bob and Mike talked about what Eric's case means, for professionals and for patient safety in a CareFusion webinar (the recording is available here). Thanks for speaking up.

I am thankful!

People who check in at Florence dot com come from all over the world, united by a desire to see better, safer healthcare systems emerge. I'm happy my efforts are contributing to hard work being done by so many others and thought it would be interesting to share where visits to Florence dot com came from last month.  (The darker the green, the more visits from that region.)

In this season of thanksgiving, I want to say how grateful I am for the opportunity to share reflections and pass along resources I value with so many of you.

This week, I heard a physician leader in a large multi-system healthcare organization talk about progress her organization has made in patient safety. The gains were substantial, and hard won, coming not from gorging on cheap Happy Meals, but from putting safety and quality at the center of the table where bright, powerful, and connected people in the organization regularly convene. These people not only plan the meal, they're accountable for what's served.

Patient safety, a component of quality healthcare, isn't the same as quality. People struggle to understand their relationship, especially in complex and evolving arenas like healthcare. Safety doesn't prove which chemotherapy regime is the most efficacious. It's what allows the one selected to be delivered as intended.

Safety may not reveal God's perfect truth. But, done well, safety is what allows humans to facilitate the activities--some miraculous, some mundane--needed to heal. If therapy fails because the chemotherapy regime selected isn't the best match for a person's genotype or stage of cancer, more work on the quality side of performance improvement is needed. But if a person dies from an accidental chemotherapy overdose or doesn't receive the curative benefits because of less obvious dosing errors, there's work to be done on the safety side.

I learn the most when people who are well into the safety journey talk about where they're stumbling. The physician who shared inspirational data about the reduction of serious, preventable safety events in her organization shook her head when asked about the barriers that prevent further gains. "It's hard," she said, "to make humans perform as flawlessly as the healthcare system needs them to."

This means that even in healthcare organizations where demonstrable gains in patient safety have been made, there's still plenty of work to be done. Improving system design and actively shaping the choices made by people who use the system is how David Marx, a systems engineer, attorney, and the author of the Just CultureTM algorithm, describes the work leaders undertake when they gather to create and sustain a culture of safety.

This year, one of my best reads was Marx' book, Whack-a-Mole: The Price We Pay for Expecting Perfection. It's a resource I'm thankful to have and one I hope you'll find helpful in your journey toward safest care, no matter where you are (in the world or on your journey).

Oh, and thanks for checking in today and on so many other days this year. Come back soon!

Thank you, Grand Rounds!

A Thanksgiving edition of Grand Rounds is up this morning at Colorado Health Insurance Insider. One of my favorite posts comes from Laika's MedLibLog, where a web 2.0 savvy health librarian shares a list of scientific journals that she follows on Twitter.

Maybe Twitter lists like this speak to me because I remember what accessing quality medical information once looked like: finding time to go to the university library, scrounging around for change, countless hours spent looking for high-end resources, doing the bump and grind with a recalcitrant copy machine (so that the prized materials might be made readily accessible in places more welcoming than the nasty, drafty, dirty library). And leaving with the nagging sense that I probably missed the best things anyway.

People who think that Twitter is a place where bores report the outcome of their children's travel soccer games are missing it. There are bores in Health 2.0. (There are bores everywhere: The 2009 word of the year is unfriend and I suspect unfollow, what you do to bores on Twitter, will pop up next year.)

But the ability to piggyback onto lists used by medical librarians, gaining access to real time output from 90 (just a start, no doubt) scientific journals a health information practitioner relies on.... well, it's enough to make you drop your dimes.

When you let go of old ways of doing things, it's nice to find something as a useful as a "follow" button.

Welcome to Lake Wobegon!

Last Monday, over at the Wall Street Journal Health Blog, Jacob Goldstein was not kind to the residents of Lake Wobegon, calling out their leaders for believing that Only 1% of Hospitals are Below Average. Goldstein's piece shares findings from a study by Jha and Epstein published in Health Affairs this month, one that links knowledge and value ascribed to clinical quality on the part of not-for-profit board chairs to the quality measures their organizations post. [link]

Additional findings from Jha and Epstein's survey of 1,000 not-for-profit hospital boards chairs between November 2007 and January 2008 include:

• less than 1/2 of respondents rated “quality” as one of their “top 2” priorities
• 3/4 reported their hospitals had “moderate” or "substantial” expertise in quality of care
• only about 1/3 had received formal training in clinical quality measures
• when clinical quality training was included in education provided to the board, the mean amount of instruction time was 4 hours 
• less than 1% rated their hospital's performance as worse or much worse than a typical hospital's performance on standard quality measures (like The Joint Commission's core measures or other publicly reported measures)

When you dive deeper to find the "take-away" lessons from data like these, resist the urge to see the chairs' overly optimistic assessments as nefarious or necessarily careless. Their estimates are, in point of fact, consistent with what people do when they are asked to evaluate their performance relative to others. Cognitive psychologists call this bias illusory superiority, and it describes the tendency of people to overestimate the degree to which they possess desirable qualities relative to others or underestimate their negative qualities relative to others. It fact, illusory superiority is referred to as the "Lake Wobegon Effect."

The real take-away lesson here is that the Lake Wobegon Effect is proportional to the specific knowledge and skill a person is asked to rate. If you ask someone who plays ball how well he plays compared to others, he will provide a more accurate assessment than if you ask someone who has no experience with ball at all. Wildly optimistic estimates of performance suggest profound lack of experience.

This means that board chairs often don't know enough about quality to know whether the organizations they oversee reliably deliver quality outcomes. I don't fault them for their "glass half full" outlook (which likely serves them and their organizations well on other fronts). But I do worry who is in a position to tell the emperor about the problem with his clothes.

Two places where you'll find this being done, albeit a bit more genteelly, is the Institute for Healthcare Improvement's Boards on Board and creative partnerships, like the one housed at SafetyLeaders.org, that help make the National Quality Forum's Safe Practices expectations come to life through free webinars and web-accessible transcripts.

Closer to home, though, finding a credible champion for quality and patient safety becomes more challenging. What powerful community leaders know and believe likely mirrors the opinion of powerful people in the organization and the community. I'm sympathetic to where board leaders find themselves these days because for most of my career, I've lived in the same "small towns" they govern.

Healthcare culture values processes that rely on knowledge contained in human memory and devalues those that rely on more mundane performance shaping measures. For a very recent example of how this thinking shapes culture, consider this tweet I picked up from a PSO insider yesterday:

"I had one surgeon tell me that checklists are for the lame and weak"

If the chair of your local hospital's board (or one of her close family members) hasn't been the beneficiary of physicians, nurses, and pharmacists who hold similar opinions, you may indeed be somewhere very good. But it's a very different place from where the average American gives, receives, and oversees care.

Healthcare is a place where "intention" still trumps "outcome." Jha and Epstein reinforce the need for senior decision makers to become familiar with how desirable quality outcomes are fostered, then measured in healthcare.

Everyone else in town needs these lessons, too. It's easy to become lost under the standard normal curve out here.

Waiting for Rabbit Redux

Good stories are sometimes told across time, and so may be the case in telling the story of how healthcare gets healed.

I found this interesting interview, Medical Errors, 10 Years Post-Op, with two of the authors of the original IOM report. It's nicely bundled with a short history of the "hospitalist" specialty. (Don't miss the history of events that have informed the evolution of patient safety at the bottom of the piece.)

While we're waiting for Rabbit, here's a link to another snapshot of patient safety-sensitive performance measures: a 2009 report, commissioned by the American College of Healthcare Executives entitled, "Bad Blood: Doctor-Nurse Behavior Problems Impact Patient Care."

Maybe get a chair.

As always, the big picture counts

Making Health Care Better, a piece by David Leonhardt in today's New York Times magazine, is simply a must-read for understanding the complex relationships that shape healthcare quality.

Here is an illustration, based on Don Berwick's "Level of Interest," that often helps me identify players, understand where they're seated, and anticipate where (and why) to expect push-back.


Berwick wrote the piece this slide is drawn from as a "user's guide" for people who would be leading improvement efforts in the aftermath of the IOM report "Crossing the Quality Chasm."

It's worth considering where the elements (drivers; incentives; methodologies) described and critiqued in the Intermountain system fit into Berwick's original construct. (This a case where the expression "same stuff, different decade" is not a slam, but rather a chance to see the evolution of welcome change.)

A better case for a system-approach to healthcare improvement cannot be made than what you'll find in the New York Times piece.

Read it. More importantly, learn from it.

Error Prevention Strategies: It's not "Sophie's Choice" folks

Last week on my Medscape medication safety blog On Your Meds, I wrote a piece about how nurses in greater San Francisco area hospitals improved medication safety. The collaborative is reporting an 88% reduction in the incidence of errors in the administration node of the medication use process over a three year period.

At the outset, it's worth noting that these results are astonishing, placing them in the "almost too good to be true" category. The study employed "observed error" methodology, a more robust method of error detection than "reported errors," (the methodology most programs and data sources rely on). The rigor of the detection methodology used in this study adds credence to the results.

But it's worth looking a little more closely at the study design to find the most important take-away lessons.

The nurses tested how adherence to six distinct performance elements in their medication administration process impacted accuracy: [link]

1. Compare medication to medical record
2. Keep medication labeled until administration
3. Check two forms of patient identification
4. Immediately record medication administration in chart
5. Explain the medication to the patient
6. Minimize distractions and disruptions during the administration process

From an engineering standpoint, these elements can be predicted to produce a robust medication administration system. Comparing medications to the medical record and checking two forms of patient identification, for example, add redundancy at high stakes junctures of the process. And "explaining the medication to the patient" creates a recovery opportunity, an engineering control that allows an error that's been set in motion to be detected and remediated before harm occurs. (The practice is also desirable from a participatory care standpoint and also is "the right thing to do" based on variety of ethical principles.)

"Minimizing distractions and disruptions during the medication use process" is the performance element that drew the most attention in the lay press, and it's what I focused on the first time I took on the issue at Medscape. Minimizing distractions at high stakes junctures of performance is a technique that high reliability industries employ. (It's why aviation personnel in the flight deck close the door and why they're subject to tighter performance expectations at altitudes less than 10,000 feet.)

What the San Francisco nurses really studied is whether adherence to a system designed to elicit a specific outcome yields the desired outcome more often than using a loosely defined, variably employed set of expectations does. Minimizing distractions was an important part of the interventions, but it wasn't the only one. The nurses did not find one "magic bullet," but rather moved from an "intention-based" process to a process that was both engineered and adhered to, something that helps explain the very favorable, highly desirable results obtained.

Understanding how these results were obtained is also important before leaping into the comparative arena, especially when the discussion is built around a "forced choice" construct that does not and should not exist. This is what I think is happening in a blog post entitled, Low Tech solution to Med Admin errors better than BCMA?

Designing the most robust system feasible to accomplish a high stakes task is how system engineers approach their work. (Risks surrounding medication administration are well documented and errors at this point remain common.)

Seminal medication safety data show that a substantial portion of errors originate in the administration phase of the medication use process.



Equally important these data reveal that patient harm is highly likely to occur as a result of errors that originate in the administration node.


It's important to recognize that errors in the administration node are problematic, not because nurses are problematic but because the systems nurses rely on and the downstream position of their work confer risk. Managing that risk has been the focus of medication and patient safety specialists over the past decade. IT solutions, specifically the ability to bar code patients and their medications, and to have key patient, drug, and order information integrated and available at the point of care, represent strategies engineers see as reliable, reproducible, and capable of sustaining change over time.

The San Francisco nurses' study did not rely upon bar code medication administration (BCMA) although it appears BCMA was used in at least some of the study sites. But what must be noted is that key performance measures in the study (namely, "compare medications to the medical record" and "check two forms of patient identification") represent standard medication safety practices that are now part of The Joint Commission's healthcare accreditation standards. While they are important elements in the system design the nurses tested, these elements are not "stand alones." They would have occurred, on some level and likely with unwelcome variability, in these hospitals during the study period irrespective of whether they were part of an intervention study.

More important to debunking ill-conceived notions that medication administration accuracy is an "either/or" proposition (pitting low tech performance measures against tech-mediated ones) is the knowledge that BCMA automates key elements of the performance measures the San Francisco nurses built into the system they tested. These include comparing medication to data in the medical record; immediately recording medication administration in the chart; and checking two forms of patient identification. Additionally, BCMA work flows necessarily foster work processes in which medications remain labeled (often in their original packaging) until the point of medication administration.

If BCMA has failed to reach its full potential in the medication administration arena, as John Poikonen questions in his RxInformatics post, the reason has less to do with the inherent fitness of the technology than how user-friendly it is designed to be; how it is incorporated into nurses' work flow; and how it is supported in the aftermath of the initial investment. Most importantly, disappointing results with BCMA likely reflect system design failures that do not take into consideration the limits of human performance when carrying out high stakes tasks. Nurses should rely on automated solutions to accomplish high stakes work and they should not be expected to multitask while using them.

Your pilots get to close the cockpit door when they perform tasks that, if carried out incompletely or incorrectly, could kill the people who depend upon them. Pilots also rely on high tech instrumentation that automates many key performance elements.

Why would you want your nurses to "pick one"?


Note: Representation of the seminal medication error data discussed here was borrowed from similar formats used by the medication safety professionals at the Institute for Safe Medication Practices. I am indebted to them, both for this depiction and the modeling upon which my knowledge of medication safety is based.

A Non-Clinical Grand Rounds

Dr. Joseph Kim is hosting Grand Rounds today at a blog devoted to exploring non-clinical medical careers. There's an interesting array of posts over there plus a chance to "shop around" the non-clinical world.

The only thing that made me wince when I took a quick look was that "patient safety" is near the top of the queue. From a blogger's point of view, this is good news, since posts placed high in the Grand Rounds narrative draw more hits to an author's blog. But from a patient safety standpoint, the perception that "patient safety" lives in the non-clinical world is a bad thing.

If you've every heard the expression, "your restaurant is only as as good as the last steak I ate there," you'll understand why. While many interests have a place at the table, the "sweet spot" in patient safety is at the point, often jagged and bleeding, where care is given and received.

There is certainly a science that informs patient safety and legitimate work to be done fostering a culture that recognizes and supports safe care. But if it's not visible at the front lines of care, it's not "patient safety."

Why a trick is still a treat

Yesterday morning, I found and posted what I thought was a great video clip, one that seemed to say all the things I am struggling to articulate in an article about healthcare culture and what happens to safety efforts when people don't report errors.

On first pass, the events captured on film jumped out at me, as the old expression "a picture's worth a thousand words" promises they will. An errant SUV, out of control for a split second, crushes two vehicles in the adjacent row of a parking lot. Amazingly, the SUV recovers, backing off of its unlucky neighbors. The video captures a brief latency, during which time one imagines the driver reflecting upon the situation and considering what to do next. Then, the vehicle slinks away, leaving viewers to judge the actions of the driver based upon what we've just seen.

I did. It looked like a vehicular telling of what I recognized, from very early in my career, as unacceptable behavior that might be excused, especially if the driver hadn't made mistakes like this in the past or had a reputation for using the errant vehicle to do good things (like deliver medical supplies to poor people). The owners of the affected vehicles might have had the damage explained in a "collateral" kind of way: These things happen when one chooses to park in a public lot and other disclaimer language, such as what's found in the "limits of liability" fine print on a parking ticket.

Mostly, I saw the lost opportunity to learn what had caused the vehicle to suddenly lose control. How did what appeared to be a routine parking manuever suddenly turn so sour? In the slinking away, I saw the opportunity to acquire information go missing. Information that, if shared, could help others avoid making a similar mistake. Did the driver mistake the brake for the gas pedal? Was he texting at the same time he was trying to park? Or did he wake up that morning and say, "By God, I think I'm going to see if I can dry hump a couple of cars on my way to the dentist?"

But enough about the lessons that could have been learned. There's another, more authentic one for people interested in cultivating a climate that promotes safety, a lesson I figured out when I demanded my son (a new driver) watch the video with me. It turned out that what I thought I had seen didn't make sense in the third or fourth viewing. The superficial "facts" (visible to everyone who views the incriminating video) don't add up. Post-hit, none of the vehicles exhibit any damage and the position of the passive vehicles in the aftermath of the event don't square with the events that one "sees" happening.

So what this video, still a great learning experience, really illustrates is the importance of moving beyond what we believe is readily apparent when investigating the root cause of error events.

People on Twitter are buzzing about the airliner that overshot the Minneapolis-St. Paul airport last week, with tweets like this being the norm:

Too late now but the #NWA188 pilots implausible story is worse for their careers than the likely truth (Zzzzz)

But this approach (that also came in the form of a tweet) shows a better way to get beyond perceptions and beliefs: Missed by 150 miles? And there are cool tools that help front line clinicians become fluent in proactive risk reduction activities, too.

It's fun to speculate about what went wrong when high profile mishaps hit the news cycle or appear to happen right before our eyes. But healthcare leaders who investigate errors and plan risk reduction strategies, benefit from using the same methodologies that FAA and NTSB professionals do.

And that's the safety lesson that really jumps out from the tricky little YouTube video.

Happy Halloween!

How we respond to error

If this is happening where you work (and I don't mean in the parking lot), your patients are not safe.

"Code Boo" at Grand Rounds

Gina at Code Blog is hosting Grand Rounds today. The Halloween theme works for me since I'm always finding something scary to write about. (Check back tomorrow for a piece on the Northwest airliner that overshot Milwaukee by 150 miles because the pilots, ummmm, seem to have lacked sufficient redundancies.)

God is great, beer is good, and people are crazy

Insanity is doing the same thing over and over again and expecting different results.
- Albert Einstein

Results from a multi-center nursing "time and motion" study show that nurses in acute care settings spend about 35% of their time documenting care, 17% on responsibilities related to medication administration and monitoring, and 21% coordinating care. I've heard Marilyn Chow, one of this study's lead authors present these data before, and she included them in a presentation given last week in an IOM webinar on the Future of Nursing.

I don't think anyone is particularly happy with these statistics. (Although it remains unclear what patients actually think since high profile evaluations, like this one from US News and World Report, measure nursing care by how mom-like the experience of being cared for is.) Real patients--that is, those who have had the experience of being hospitalized and understand that the circumstances that land them there necessitate far more than a chipper smile and a well-timed fist-bump--might be able to evaluate nursing care using different metrics. But, for now, it appears we're living with "% of patients whose nurses were ALWAYS polite and communicative." Sigh. (Can I just say that when I'm an inpatient, I appreciate polite and communicative behavior on the part of all of my caregivers?)

It's hard to look at Chow's data and not be struck by a significant mismatch between intention and outcome. Surely this is not the best use of valuable, high cost resources.

But what makes Chow's presentation worth studying is that, beyond Slide 4, she gets out of the box, tossing out fresh ideas about how nurses will nurse in the future. And why they should. Plus who will benefit. And how technology will enable it. Review the 11 slides in this presentation for inspiration.

If you think I'm crazy, remember what Einstein said.

Car dating & cognitive dissonance at Grand Rounds

Here's a link to SharpBrains, where yesterday's host Alvaro Fernandez brought together Grand Rounds (a forum for medical bloggers) and Encephalon (a forum for people who blog about the brain and mind). Alvaro offers a tongue-in-cheek, "What a nice surprise! Hello. Nice to meet you" to both groups.

The introduction has already been made.

The need to recognize the inherent fallibility of humans (and design systems that are reliable in spite of the predictable faux pas humans make) was articulated nearly a decade ago in the first IOM report, To Err is Human. Alvaro's invitation, his need to suggest that healthcare professionals dip into the cognitive psychology well, is telling. It's surely part of the reason we've yet to post measurable gains in preventing inadvertent medical error.

It occurs to me that when introductions lead to a relationship, it's because both parties perceive a benefit. It's been ten years, and in the U.S, we're still discussing whether tired residents are really as tired as other tired people. And entertaining other intention-oriented ideas, like "Follow the 5 Rights." This suggests cognitive dissonance between the safety paradigm we have and the one we need. Apparently, "we're just not into you," SharpBrains.

Healthcare remains distinguished from other high consequence industries by the degree of personal vigilance we tolerate and rely on. No matter where you or your organization may be on the journey toward improving patient safety, you should agree to a second date with the folks who study the performance parameters of humans.

Applying lessons learned to healthcare workers and the systems used to deliver care is a necessary step in eradicating the public health problem called "medical error."

Why they have to: Patients and patient safety

Last week, Bob Wachter, a patient safety leader I admire, wrote a post Can Patients Help Ensure Their Own Safety? More Importantly, Why Should They Have To? As the title suggests, Wachter addresses both the utility of patient participation in safe practices and the necessity for this.

On occasion, these issues make my own hard drive blink. They did most recently when I considered how patient involvement squared with principles used to engineer highly reliable systems while writing From Safe Practices to Safe Patients: The Evolution of a Revolution (published on the Medscape platform last month.) At one point, I considered jettisoning the piece, convinced that allowing variability of the magnitude that patients (humans) necessarily introduce to a system couldn't be defended, let alone operationalized.

Wachter seems close to casting patients overboard, too. He rightly points out that the ability to self-advocate varies both between individuals (who possess differing knowledge, abilities, desire, and social support systems) and within one individual across time (subject to things like severity of illness, level of consciousness, and use of medications). Systems engineers (one is quoted in his post) tell us that variability is the enemy of stability. And finding variability in a system and driving it down is what gets these folks out of bed in the morning.

I've wanted to do this kind of "people parsing" on occasion myself.


Who wouldn't like to eliminate the outliers in the patient population we serve? Hypervigilant, distrustful patients can be problematic. At the other end of the self-advocacy continuum are unconscious Jane Does. They, too, interrupt work flows. But eliminating variability in measures that inform patient safety risks treating all patients like the least common denominator: the "bar" gets set at the level of the anesthetized patient.

And here's the other problem: Neutralizing patient input in patient safety assumes that the system is sound. That is, it produces reliable results if you just sit back and let the system do its thing.

Wachter does something I like to do: comparing the experience of being a passenger on a commercial aircraft to being a patient. I travel a lot, enjoy flying, and I'm perfectly happy assuming the safety duties expected of every other passenger on board. I wouldn't think of offering to lend a helping hand to those on the flight deck.

A commerical aircraft crashes 1 time in every 6 million departures. The fitness of systems used in commercial aviation clearly do not depend upon input from me. I'm okay with saying that if I get booked on the unlucky 1 in 6 million flight, "It's my time." But safety leaders in aviation are not. They continually strive to improve the system, to find ways to drive the incidence of error down, further diminishing the likelihood of 1 in millions events.

A preoccupation with making things safer is what distinguishes aviation (and other high consequence industries with reliable safety records) from healthcare. There's no doubt that the "alert" signals engineered into aircraft are easier to read than those built into humans. But that does not diminish the effectiveness of an alert.

I've been a nurse for a long time, and I suspect I share many of Dr. Wachter's feelings about what professionals should do for their patients. We have duty and desire, but, at this point in time, we do not have the means. Wachter is right to call for systems that turn intention into outcome.

But the answer to, "Why should they have to?" is that safest care won't happen without them.

Safety Nurse's Top 25 Tweeps for Patient Safety: October 2009

I'm happy to share this 2nd, updated list of 25 tweeps who are advancing the science of patient safety through Twitter.

This is not a list of "who's who" in the world of patient safety (although tweets hashtagged #ptsafety will frequently take you to the work of patient safety researchers, clinicians, and exemplars). Rather, it's a list I maintain to help me remember how broad the patient safety stakeholder base is and to keep track of key elements that inform patient safety. (A person or entity must be active in the Twitterverse to make the list.)

If you picked my brain this month, this is who I would tell you to follow:

1. @ahier Prolific and passionate. Interest in healthcare and IT bumps him into #ptsafety on a regular basis. Forward-thinking, sm early adopter, helps spot "how to."
   
2. @alinahsu A systems-thinking, Lean enterprise tweep who finds & RTs #ptsafety sensitive information.
3. @deadbymistake Visible, helping to keep the issue of med errors in the news. Interesting use of Twitter to sustain investigative reporting efforts.
   
4. @dirkstanley Hospitalist, CMIO. Did someone already say, "Your doctor is on?" Say it again. Not deep into #ptsafety tweets but follow him to take a pulse from the frontline.
   
5. @ePatientDave His "Give me my damn data" cry sets the bar for pt visibility in demanding access and transparency.
   
6. @ecri_anderson Editor of ECRI Institute's risk management & #ptsafety publications. Outreach from a PSO insider.
   
7. @hospitalrx Long-time advocate of automation. His mission? "Protecting patients & caregivers one bar code at a time."
8. @IHIOpenSchool Useful tweets from demonstration project engaging next generation of HC professionals. Outreach may be a tipping point for culture change.
   
9. @INQRI Researching and communicating nurses' contributions to safety scaffolding. Frequent #ptsafety sensitive tweets & resources.
10. @improvementmap Another IHI endeavor. Regular RTs of worthy thoughts & ideas beyond their own portfolio (of worthy thoughts & ideas!)
    
11. @ismp1 President of ISMP, a nonprofit, multidisciplinary, drug safety agency. Unflinching advocate, now on a PSO platform.
12. @JCommission Cautious entry into the Twitterverse. Tweets helpful & often #ptsafety sensitive. More please.
    
13. @jfahrni Pharmacist, infomatics. Tweets show how change hits the frontline. Exemplary use of the 140 constraint!
14. @JohnSharp Infomatics research. HIT, the great patient safety enabler, now has a participatory healthcare champion.
15. @JustinHOPE Parent founder of children's patient advocacy org. Shows that perseverance pays. Pros count on her tweets to find high-end #ptsafety info.
16. @medusesafety Tweets from the American Society of Medication Safety Officers. Leaders in a high-stakes, interdisciplinary milieu.
17. @midwifeamy Using participatory healthcare to engage women. "If it ain't broke, don't fix it" deserves a voice in #ptsafety. Her blog raises issues that inform safety.
    
18. @NPRhealth High-end analysis and links to big pic set-ups that impair health (and #ptsafety). No Happy Meals here.
19. @paulflevy Hospital CEO who blogs. Models transparency, leader engagement in #ptsafey. Exemplary posts not rare.
    
20. @PSeditor Editor HCPro, Inc. Fosters engagement. Nurtures, networks effectively using 2.0 (without shameless self-promotion). Others could emulate.
    
21. @quantros Tweets to improve patient safety & reduce medical errors in the US healthcare system from inside a PSO. Always on target.
22. @SusanCarr Editor, Patient Safety & Quality Healthcare. Models how traditional modes for communicating #ptsafety info can morph. Original tweets always worth a look.
    
23. @tully3000 Quality and #ptsafety RN insider willing 2 go outside of the listserv box. Thinker with broad scope of #hc & #hcsm interests. Will be waiting to welcome others.
    
24. @writeo 1 of 2 consumer members of OR Pt Safety Commission. Tweets about process & progress of groups like these help others. More, please.
25. @WSJHealthBlog Obviously, not #ptsafety only, but high profile news informing pt safety is there. Good fodder for systems thinkers.

Participatory Healthcare at Grand Rounds

Grand Rounds is a "must visit" place today irrespective of whether you're a consumer, healthcare provider, or have another dog in the fight to improve healthcare. You'll find clear explanations of what "participatory healthcare" is and have a chance to assess how it's emerging.

One thing about participatory healthcare that jumps out at me is how well it aligns with the way I was taught to approach patient care when I was an undergrad nursing student in the mid '80's. That curriculum also came with a hefty dose of "change management" theory, something that drew disdain from the "where's the beef?" crowd and, unfortunately, didn't change much.

But what does seem to be changing things is the information revolution. Patient access to information, ideas, outcomes, and communication modalities is doing more than just shoring up foundational changes in "how we do things around here," (the easiest way to describe healthcare culture). These changes must occur to make the delivery of healthcare more reliable, more safe.

I see patient engagement as transformational, meaning we're likely to get somewhere better as a result of letting patients take the lead for part of the journey. So take a trip to Survive the Journey and see how far we've come.

When you do, you'll find that a number of the people who contributed to the participatory healthcare Grand Rounds appear on the inaugural list of "Top 25 Patient Safety Tweeps" I published last month, among them Dave DeBronkart (epatientDave), Amy Romano (midwifeamy), and John Sharp (JohnSharp). The experience of patients is central to efforts to improve patient safety. So are initiatives and incentives arising from clinicians, organizations, payors, industry partners, regulators, and academics. I'll publish an updated list this Friday, 10/16/09.

I welcome nominations of individuals or organizations from any of these categories for consideration on Safety Nurse's Top 25 Tweeps for Patient Safety list. The entity must have a current, active presence on Twitter. The volume of tweets is less important than the quality of patient safety information that's passed along.

Thanks for participating!

Monday morning quarterback: The Little 2

The world of patient safety did not shake with high-profile standards, policy, or funding changes communicated via Twitter last week. But I found a few nuggets to pass along, things that promise both hope for the future and also suggest that past missteps may continue to hobble patient safety.

First, a smile:

Ilene Corina, a patient safety advocate, recounts what she found impressive at the National Patient Safety Institute's second annual Lucian Leape Institute gala. The changes in medical education previewed in one roundtable Ilene attended suggest that "reward what you value" is beginning to inform medical students' experiences. Changes which would enhance medical students' exposure to patient safety are in draft.

The recommendations put forth in forums such as this one serve as a "pulse check" for major patient safety initiatives. Ilene noted, with some dismay, how slowly patient safety-sensitive changes take hold in high stakes venues, like academia. She's right when she says the public assumes we are much further along, as my experience this weekend revealed.

My brother-in-law, an engineer, nearly choked on his steak Saturday night when I told him there were 4,000 wrong-site surgeries reported in the U.S. last year. (His number-crunching mind grasped the defect quotient this number represented before the meat bolus had cleared his trachea.) So a take-way corollary--learned not in a seminar but in a Houston steakhouse--is this: In the interest of patient safety, don't share disturbing facts when a healthcare consumer has a mouthful.

And something that rankles:

Brian Ahier wrote a short must-read piece You don't have to use EHR, in which he quotes Dr. David Blumenthal, National Coordinator of Healthcare IT at HHS. Brian puts the facts out, so I'll simply ask this follow-up question: "Would any other contemporary high consequence industry contemplate operations that bypassed electronic transmission of high-stakes data?"

In healthcare, when we finally get a Model T, we immediately tie an ass to the bumper. Here we go again.

My guess is that Dr. Blumenthal is hand-patting those who have fears, probably legitimate, about the misuse of health data. But he would be better served to act to shore up the security of EHRs. Providers cannot be responsive given the complexity modern healthcare absent data automation. Outcomes will suffer until the data-sink is resolved. People who are hand-patting about security concerns should take a turn alongside the clinical people who hand-pat the families of people who die as a result of lousy communication.

What I'm watching this week:

Grand Rounds, the weekly blog carnival, is taking on participatory healthcare this week. I expect to learn more about the power of patients to shape healthcare and improve safety.

Participatory Safety

Patient safety is a natural fit with participatory medicine. And not because initiatives that include the word "patient" should seek to involve patients in some nominal, "so glad you could make it" fashion. I don't picture patients manning the Guest Book at the reception when I consider the potential of patients to improve the safety of care.

Patient safety is a scientific discipline, one that seeks to make complex systems work reliably. Systems turn intention into outcome whether you're flying a plane or reconstructing a breast.

Transparency, disclosure, error reporting, and an urge to prevent errors by learning from the mistakes of others are hallmarks of patient safety. People who champion the science of patient safety borrow from cognitive psychology, systems engineering, and human factors, recognizing the inherent fallibility of humans and looking for ways to mitigate the consequences of human error. These are principles patients should know.

Healthcare has suffered from the erroneous perception that good people automatically produce good outcomes. Both patients and providers have had a role in shaping this belief. Since we're all seated at the grown-ups' table, let's get this on it: Healthcare providers are fallible humans. It's not "if" we make mistakes, it's when. What really matters is the consequences of these mistakes, that is, whether they make it to you.

In highly reliable systems, the intended outcome is delivered under both normal circumstances and when conditions destabilize or become hostile. Intended outcomes arise from work processes that build in barriers, redundancies, and lots of opportunities to discover and mitigate errors set in motion before they cause harm. Highly reliable results do not come because the captain of an aircraft is godlike or the engineer at the nuclear power plant was the smartest kid in his class. High reliability comes when competent people:

• perform within a system designed to accomplish the task at hand,
• believe that the system could fail, and
• are empowered to act when a threat, or potential threat, to safety is perceived

It's fair to say that the 100,000 or so unintended deaths due to medical errors and healthcare acquired infections that occur in the US each year disqualifies our industry from being a highly reliable one. So what does participatory healthcare mean for patient safety?

Tons, but here's one of the most obvious: When a patient is seen as a participant in, rather than the object of, care, the system becomes more stable. At its most basic, patient participation adds a valuable redundancy at high stakes junctures of care (as occurs when a patient confirms identity before blood is drawn, verifies the affected area before a biopsy is underway, or asks a provider, "Have you washed your hands?"). Moving into less concrete domains, patients are uniquely positioned to uncover a wide array of errors that have been set in motion.

Here's an example, one that illustrates how patient engagement prevented a serious warfarin overdose:


I know a lot about this case because it happened to me. I derailed a 17.5 mg overdose of warfarin which had passed through a series of high-end automated barriers, including electronic MARs and bedside bar-code medication administration. (You can read the complete story here.)

The take-away lesson is that the warfarin overdose wasn't averted by any special "insider knowledge" of warfarin or the medication use process that I possessed. My participation came in the form of a question ("Do you usually give someone who is close to having a therapeutic INR a big dose of warfarin?"). The nurse's willingness to believe that a concern raised by a patient merited investigation is what allowed the error to surface.

From an engineering standpoint, "patient engagement" takes on value beyond its ability to help people understand a plan of care, decide if it's for them, and manage barriers. Engaged patients add a valuable layer of error detection, one that often does not exist if the patient cannot or will not participate in care (which, by the way, is why advocates and surrogates are such important players in patient safety.)

To make participatory processes work for patient safety, look for opportunities to engage in safety initiatives at the system level. I maintain Florence dot com as a real-time patient safety primer, a place where both patients and providers learn about the science that informs safest practices. Daily tweets that run here point to information and resources that represent best practices, case reports, exemplars, and stumbling blocks. I hope you'll find helpful information here and let me know when you have a safety-sensitive story to share.

Because before you get to the bedside, you want to be sure you're at the table.