Wednesday, March 18, 2009

A Picture's Worth One Thousand Words

When I made "patient safety" my business, I stepped away from specialty practice in intrapartum and high-risk antepartum nursing care, a decision that is sometimes difficult to explain. Last week, I wrote about how the perception of patient safety as a warm, fuzzy, intention-based goal can get in the way of actionable things--like workflow analysis, process mapping, and harnessing the power of technology--to deliver efficiencies, reliability, and economies of scale.

Another aspect of the career shift has been the risk of becoming a "glass half-empty" kind of girl, a perpetual naysayer who tells earnest, well-intended, and increasingly cash-strapped healthcare professionals, "Really folks, this is simply not enough. Have you forgotten that medical errors are the 8th leading cause of death in the U.S?” Last week, Oprah helped me out, hosting the Quaids and reminding us that "every year in the United States, more people die from medical mistakes than from breast cancer, AIDS and car accidents…combined. It's a major, major health issue that will touch almost every single American at one point in our lives."

I’m not a person who sees the glass is half-empty, nor am I an apologist. So I’ll share here what’s helping me to reconcile the irrefutable mismatch between intention and outcome that is healthcare today.

First, it may be helpful to simply acknowledge that errors are very common in healthcare. So common, in fact, that the Agency for Healthcare Quality and Research has endorsed a taxonomy to describe and categorize them. While this may be shocking at first glance, it’s actually good news: Using a specific nomenclature to describe events and categorize them is an epidemiologic approach to problem solving. Taxonomies are used in the study of other vexing problems (like breast cancer, AIDS, and car accidents). So, it’s reasonable to expect that similar processes would be used to diminish the incidence of our problem: medical errors.

While the charge “First, do no harm,” may resonate with many clinicians, this is a goal statement, not a process map. “Just Do It!” just doesn’t, well, do it when it comes to solving significant threats to health.

If you visit AHRQ’s Patient Safety Network, you’ll find the error taxonomy is searchable by a variety of categories (for example, “care setting”; “clinical area”; “type of error”). The one I use most often is “approach to patient safety” because this query lets me “connect the dots,” seeing how specific strategies (like “patient hand-offs”) are seated within larger motherships (like “Communication Improvement”). The taxonomy maps the current “method to the madness,” and leaves room for new ideas. (You’ll notice that the labels I apply to each post at Florence dot com often include key words from the patient safety taxonomy.)

Second, everyone makes mistakes. We may not mean to, but we do. There is a strong body of evidence suggesting that in the aftermath of an error, healthcare professionals struggle with what actions to take and how to reconcile their feelings about having been involved in an error. And a recent study in the Journal of Patient Safety suggests frontline clinicians remain conflicted about disclosing, discussing, and reporting error, despite efforts to increase transparency, promote reporting, and look at error in context. (If I were to apply a label to the discussion right now, I’d choose: culture of safety.)

It may be easier to start talking about errors that happen in healthcare settings by talking about errors that didn’t. Take a look at the photo below and see if you can guess what happened when I cooked breakfast at my church a few weeks back.

Yes, I washed my hand with a hand sanitizer product intended to be used without water, an activity that neither cleansed nor sanitized my hands.

Obviously, I didn’t read the label. A look at my kitchen sink will help you see why:

(In case you can't read the label--something that's difficult to do even in here in my kitchen--the little-bitty font just above the green leaves says, "Hand Soap.")

Two distinct products that share similar packaging, similar color, and similar placement: an error-prone set-up in the community. And an error-prone set-up at work.

This is not to say that I think the consequences of mixing up products in a community setting and the consequences of mixing up products (particularly medications or cleaning agents) while on-the-job are equivalent. In fact, it’s precisely because the risk of harm is so much greater when error occurs in a healthcare setting that processes on-the-job need to be far more robust than what we typically use at home.

I hope you’ll come back as this discussion evolves! (Feel free to use the comment section to share your thoughts with me and with each other.) And in the meantime, I hope you'll stay safe!

Next time: LASA: It’s not just another bad abbreviation.


Anonymous said...

This is an interesting subject because it is so true. In response to your pictures of soap and Hand sanitizer, this makes me think about an issue that makes me kind of frustrated. This issue has to do with washing your hands in a restroom and not having any way to get out of the bathroom with out retouching the dirty door handle leading out. Really there is only one way to solve this problem and that is to grab a paper towel and grab the door handle on your way out instead of retouching the handle to get out. The only problem with this is, you then have clean hands coming out of the restroom and your holding a dirty paper towel with nowhere to through it away! I have noticed that in some restrooms, there are trash cans that are strategically placed at the exits of the restroom so that as you are leaving you can toss your dirty paper towel in the trash after you have opened the door. I just wish all places would provide a trash can at the door to do this. It really just seems so pointless to wash your hands really well once you have gone to the restroom to simply turn around and touch the door handle that everyone touches on their way out of the bathroom. (Including those that didn't wash their hands after going to the restroom)This is just gross! Can we say infection control!

Barbara Olson, MS, RN, FISMP said...

You're thinking like a systems analyst! Telling people, "Wash your hands," is fine, but making it easy and not overly burdensome to comply with the expected behavior is more effective. Managing the barriers that prevent people from doing the desired/"right" thing is a system-level solution.

Thanks for dropping by and sharing your observation!


Creative Commons License
Florence dot com by Barbara Olson is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.