One of my favorite patient bloggers has a great post up today. Kairol Rosenthal at Everything Changes shares important things about what patients can do to help prevent medical error. Check out How Do You Prevent Errors in Your Care?
Campaigns that help patients become more active, more visible in their care are on the rise. The Joint Commission has one I like: Speak Up. The focus of campaigns like these--rightly, I think--is on behaviors patients and caregivers should engage in. But it's interesting to know the science behind the recommendations.
Patients are the last line of defense in a complex system of care. Ideally, errors are prevented (through strong system design and rigorous adherence to the processes designed to avert human error). But the next-best thing to preventing an error is to detect it and mitigate negative consequences before the error reaches and harms a patient. This is why the patient's (or advocate's) voice is so important. They are the last line of defense that can detect an error that's been set in motion. Knowing what to expect helps people recognize when things are not going as expected.
For example, asking "Did you wash your hands?" helps avert a common error of omission set in motion close to the patient. Errors arising close to the point of care are particularly hard to detect. (They stand in contrast to things like a physicians' prescribing error which--while potentially serious--routinely undergoes scrutiny by pharmacists and, in a hospital setting, nurses.) The likelihood of detecting and correcting an upstream error (like a wrong dose or wrong drug prescribing error) is good. The likelihood of detecting a downstream error (like failure to perform hand hygiene) is not.
Many clinicians are working to change cultural norms in their workplaces, things that discourage patients and professionals from speaking up when they have a concern about how care is unfolding. It's a viable strategy that helps cure a healthcare epidemic.
Kairol thinks they should be wearing a ribbon.
Tuesday, February 9, 2010
Saturday, January 30, 2010
Enough! Hidden Hazards that Impair Safety
This morning my husband, my son, an exchange student and his host brother are holed up in what my mom would call a "no tell mo-tel" 30 miles south of snowy Nashville where I am waiting to greet them with tickets to tonight's Thrashers-Predators game. The boys gave up trying to complete the drive from Atlanta last evening when my husband, who grew up in Canada, said, "Enough." And not a lot more.
Unpredictable things that derail what we intend to do are annoying, and they can be dangerous. Like icy patches hidden under the snow, they're often hidden. Hazards are on my mind today.
On a larger scale, I've been reflecting about hidden places where safety gets derailed ever since a link to an article in the UK hit my Tweet stream last week. The headline and the original tweet used precious characters to say this: "Nurses who overdosed two Heartlands Hospital cancer patients escape punishment by professional body." The re-tweeted version that came to me included these words: "Sometimes sorry is not enough."
Based on the published account of these errors, the tragic events that resulted in the deaths of two patients did not happen because the nurses and physician intended to harm them. Rather, the processes they used to provide care on a regular basis failed when they were subjected to a drug's hidden hazard: Safe dosing of the drug involved, amphotericin, depends upon whether the specific product on hand is in a conventional or liposomal formulation.
The Institute for Safe Medication Practices defines a series of routine checks and balances that should be in place in clinical settings where amphotericin is used. Differentiating--calling out in a way that is obvious and unmistakable to all clinicians who prescribe, dispense, and administer drugs with liposomal formulations--is one of the strategies necessary to prevent these errors. It's also worth noting that liposomal formulations of drugs are part of a group designated as "High Alert Medications" so-called because they are highly likely to cause grave harm when used in error.
The process the clinicians used the day two people in the UK died failed because it was insufficient to prevent or detect a potentially lethal error that was set in motion. The nurses told the professional board that they were "very sorry," words that seem to have fueled the grief of the families and caused some in the global community to judge them, too.
"I'm sorry," no matter how sincerely felt or expressed, does not restore the dead to the living. That is not the purpose of expressing remorse nor for accepting an apology. The survivors of a terrible tragedy caused by medical error must be supported in how they choose to proceed, dealing with the unwelcome life-altering changes such events hoist upon them. Survivors must be free to accept or not accept expressions of regret (although many find sincere apologies by individual clinicians and organizational leaders lessen their burdens).
But how we treat the people at the "sharp end" of a tragic system failure is ultimately a measure of safety culture. And it's a place where where good people (including many patient safety experts and healthcare professionals) slip on a hidden hazard. Saying that the nurses involved in this error "escape punishment" suggests they deserve punishment. And "sometimes sorry is not enough" leaves me scratching my head. What would be enough?
Postscript: You can access a recording of the IHI webcast mentioned above by clicking this [Link].
Unpredictable things that derail what we intend to do are annoying, and they can be dangerous. Like icy patches hidden under the snow, they're often hidden. Hazards are on my mind today.
On a larger scale, I've been reflecting about hidden places where safety gets derailed ever since a link to an article in the UK hit my Tweet stream last week. The headline and the original tweet used precious characters to say this: "Nurses who overdosed two Heartlands Hospital cancer patients escape punishment by professional body." The re-tweeted version that came to me included these words: "Sometimes sorry is not enough."
Based on the published account of these errors, the tragic events that resulted in the deaths of two patients did not happen because the nurses and physician intended to harm them. Rather, the processes they used to provide care on a regular basis failed when they were subjected to a drug's hidden hazard: Safe dosing of the drug involved, amphotericin, depends upon whether the specific product on hand is in a conventional or liposomal formulation.
The Institute for Safe Medication Practices defines a series of routine checks and balances that should be in place in clinical settings where amphotericin is used. Differentiating--calling out in a way that is obvious and unmistakable to all clinicians who prescribe, dispense, and administer drugs with liposomal formulations--is one of the strategies necessary to prevent these errors. It's also worth noting that liposomal formulations of drugs are part of a group designated as "High Alert Medications" so-called because they are highly likely to cause grave harm when used in error.
The process the clinicians used the day two people in the UK died failed because it was insufficient to prevent or detect a potentially lethal error that was set in motion. The nurses told the professional board that they were "very sorry," words that seem to have fueled the grief of the families and caused some in the global community to judge them, too.
"I'm sorry," no matter how sincerely felt or expressed, does not restore the dead to the living. That is not the purpose of expressing remorse nor for accepting an apology. The survivors of a terrible tragedy caused by medical error must be supported in how they choose to proceed, dealing with the unwelcome life-altering changes such events hoist upon them. Survivors must be free to accept or not accept expressions of regret (although many find sincere apologies by individual clinicians and organizational leaders lessen their burdens).
But how we treat the people at the "sharp end" of a tragic system failure is ultimately a measure of safety culture. And it's a place where where good people (including many patient safety experts and healthcare professionals) slip on a hidden hazard. Saying that the nurses involved in this error "escape punishment" suggests they deserve punishment. And "sometimes sorry is not enough" leaves me scratching my head. What would be enough?
- An Ohio pharmacist is prosecuted, convicted, and jailed for criminal conduct following the death of a toddler who received a toxic chemotherapy infusion: Jail Time for a Medication Error – Lessons Learned from a Pharmacy Compounding Error. Is this enough?
- A midwife in the UK hangs herself, believing she is blamed for the death of an infant that followed a failed hand-off of key clinical data. The details appear in Midwife hanged herself thinking she was to blame for baby's death. Enough?
- A new resident physician commits suicide following a medical error. Expectations of perfection and what happens to people when systems are not strong enough to overcome human error are shared in Words fail, a moving tribute written by her colleague. Enough!
Postscript: You can access a recording of the IHI webcast mentioned above by clicking this [Link].
Monday, January 18, 2010
Not perfect
In the past few weeks, I've managed to lose my keys, my iPhone, and my way, predictable lapses known to occur when a person doesn't sleep or shower in the same place enough. So error, and how to mitigate predictable errror, had been on my mind.
To that end, I now possess 3 identical, well-parsed travel kits, one for home, one for my home away from home, and one for my gym bag. Standardize. Simplify. Before clicking "send," I ask for a second set of eyes on high-stakes transactions (like flight bookings). Independent double checks. Redundancies.
I know what reduces the chances that simple human error will occur or cause major set-backs in many processes. Last week, I was busy putting this knowledge to work for myself.
So it seemed like an odd time for counter-intuitive messages--things that show the benefit of imperfection--to crop up. But on Friday morning, I found myself captivated by a story about a mistake. (You can listen to this recollection, made more special because events weren't carried out as planned, in Story Corps' "When the tooth fairy overbooks, helpers step in," a daughter's precious memory of a father's slip.) And today I found Kent Bottles' interesting piece about why failure is important, which called upon a classic article "Teaching Smart People to Learn." (There's a link to the pdf in Kent's post.)
Trying to find the silver lining in the mistake cloud reminds me of a two quotes I used to keep on the bulletin board above my desk: Experience is what you do get when you didn't get what you wanted and Experience helps you recognize when you've made the same mistake twice.
Bon voyage! Safe travels!
To that end, I now possess 3 identical, well-parsed travel kits, one for home, one for my home away from home, and one for my gym bag. Standardize. Simplify. Before clicking "send," I ask for a second set of eyes on high-stakes transactions (like flight bookings). Independent double checks. Redundancies.
I know what reduces the chances that simple human error will occur or cause major set-backs in many processes. Last week, I was busy putting this knowledge to work for myself.
So it seemed like an odd time for counter-intuitive messages--things that show the benefit of imperfection--to crop up. But on Friday morning, I found myself captivated by a story about a mistake. (You can listen to this recollection, made more special because events weren't carried out as planned, in Story Corps' "When the tooth fairy overbooks, helpers step in," a daughter's precious memory of a father's slip.) And today I found Kent Bottles' interesting piece about why failure is important, which called upon a classic article "Teaching Smart People to Learn." (There's a link to the pdf in Kent's post.)
Trying to find the silver lining in the mistake cloud reminds me of a two quotes I used to keep on the bulletin board above my desk: Experience is what you do get when you didn't get what you wanted and Experience helps you recognize when you've made the same mistake twice.
Bon voyage! Safe travels!
Sunday, January 17, 2010
AHRQ's PS Net: Spiking the Kool-Aid with Truth Serum
Florence dot com has been on holiday. As I reflect on the hiatus, it's helpful to remember that the real Florence spent the final twenty years of her life in bed. (That's not what I've been doing, but it's information that helps establish expectations.) At the outset of this renewal, there are a few things about patient safety worth reiterating.
Few people are really "new" to patient safety. You become seasoned--recognizing what's gone right and what has or may have gone wrong--as soon as you begin to give or receive healthcare. Patient safety, simply put, is the science of preventing people from being harmed as a result of their need to seek care and how care is provided.
If you're a seasoned healthcare provider but new to the term "patient safety" or uncertain how it captures work you may be familiar with, I recommend viewing the Agency for Healthcare Research and Quality's Patient Safety Network (AHRQ PS Net) site. It's a place where initiatives and approaches--some very familiar to bedside clinicians--are organized and categorized according to "where stuff happens," "how stuff happens," "why stuff happens," and "how to prevent stuff from happening." You get the point.
The site may sound academic, but it's not. Behind the taxonomy and useful glossary are a lot of easy-reads. Web M&M presentations, for example, rival prime time drama. (Just imagine the Kool-Aid in the screenwriter's room at House being spiked with truth serum.)
I hope you'll enjoy the (mostly) real-time dialogue about patient safety (and other things that capture my attention or imagination for a moment or two) this year!
Few people are really "new" to patient safety. You become seasoned--recognizing what's gone right and what has or may have gone wrong--as soon as you begin to give or receive healthcare. Patient safety, simply put, is the science of preventing people from being harmed as a result of their need to seek care and how care is provided.
If you're a seasoned healthcare provider but new to the term "patient safety" or uncertain how it captures work you may be familiar with, I recommend viewing the Agency for Healthcare Research and Quality's Patient Safety Network (AHRQ PS Net) site. It's a place where initiatives and approaches--some very familiar to bedside clinicians--are organized and categorized according to "where stuff happens," "how stuff happens," "why stuff happens," and "how to prevent stuff from happening." You get the point.
The site may sound academic, but it's not. Behind the taxonomy and useful glossary are a lot of easy-reads. Web M&M presentations, for example, rival prime time drama. (Just imagine the Kool-Aid in the screenwriter's room at House being spiked with truth serum.)
I hope you'll enjoy the (mostly) real-time dialogue about patient safety (and other things that capture my attention or imagination for a moment or two) this year!
Friday, December 18, 2009
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.
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.
Wednesday, December 16, 2009
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!
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!
Tuesday, December 15, 2009
Grand Rounds at Charlotte's Web
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.
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.
Friday, December 11, 2009
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.
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.
Tuesday, December 8, 2009
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.
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.
Sunday, December 6, 2009
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!
Thursday, December 3, 2009
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.
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.
Tuesday, December 1, 2009
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!)
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!)
Thursday, November 26, 2009
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 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.
Saturday, November 21, 2009
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!
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!
Tuesday, November 17, 2009
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.
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.
Friday, November 13, 2009
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)
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.
Monday, November 9, 2009
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.
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.
Sunday, November 8, 2009
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.
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.
Thursday, November 5, 2009
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.
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.
Tuesday, November 3, 2009
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."
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."
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