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!

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.

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 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.

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!

Trolling for patient safety in social media

People are asking lots of questions about social media (SM). More specifically, I think, we're wondering whether Facebook, Twitter, and blogs have meaning beyond what I've recently counseled my 21 year old daughter to beware of: trolling for amusement.

SM can knock on the door of its evil cousin, "addiction." It has, on occasion, claimed rather large chunks of my life in a way I failed to notice or care about while engaged. So am I a Twaddict? A Blogopath? Am I locked in to Linked-in?

Life is meant to be lived. Not mindlessly thumbing through electronic messages in hopes of finding something more interesting than what's happening where you are. So I've been reflecting about whether time spent at social networking sites can be counted as really living?

I don't know for certain that social media is "life," but I think it reflects life. More specifically, it's a barometer of culture. As a person who follows how culture in healthcare organizations impacts safety very closely, I find that SM opens a window into experiences and settings that are otherwise closed. Since you can only learn--individually and collectively--from mistakes and near-misses that you know about, I think greater transparency is among the greatest gifts SM offers the discipline of patient safety.

Here are just a few examples that captured my attention in the past few months. Since this is not a forum to fully deconstruct each event, I'm titling each to show the behavior or belief that undermines safest practice:

• It's okay to carry things that will be injected into patients' veins in the same manner as a Bic pen: A promising young nurse shares stories about her entry into the nursing profession. One day, she photographs what she carries in her pocket. Scissors, tape, "flushes," and pens are among the things she finds helpful to store there.


• We all have nights from hell: A seasoned intrapartum nurse describes a busy shift where she cares for multiple high-risk patients, all of whom are receiving high alert medications (those highly likely to cause harm if used in error). Staffing inadequacies and a pervasive "get 'r done" culture prevent post-procedure medication and patient monitoring. Everything turns out okay in the end.


• Smart people don't make stupid mistakes: A resident caring for a patient receiving intraoperative dialysis takes a picture of the machine used to perform dialysis. She questions whether it's necessary to have adjunct labeling ("Dialysis Only. Do Not Drink") affixed to the front. And she asks this in a way that suggests this photo may wind up in an upcoming collection of "Darwin Awards."

People share their stories and experiences in SM venues in ways that often remove standard filters, many of which we rely on to be successful (or at least functional) in "real life." Bloggers and tweeps are not in "inspection mode," and they're not usually engaged in defensive posturing. Most accounts come from regular people, telling stories about how they take on the business of providing care. Details about obstacles faced, choices made, and opinions expressed reflect the culture of healthcare.

I saw this from Dr. Val, tweeting from a live speech by Francis Collins last week:

Collins: If you want to find a cure for cancer, you don't need to just research cancer. The answers may come from somewhere else. #RSOS.

So, too, with curing what ails healthcare.

Safe Practices to Safe Patients

Understanding the "science behind the compliance" of patient safety is important for a number of reasons. Here are the ones I find the most compelling:

• When process changes are made, professionals who are impacted deserve to know why a change is occurring as well as what they are expected to do. (People don't roll out of bed to go to work and do things they perceive as useless, stupid, or burdensome simply because they're told "Joint Commission requires x, y, or z.....").
• Healthcare is distinguished from other high-stakes endeavors (like aviation and nuclear power) by the number and complexity of distinct high-stakes processes that individual clinicians engage in each day and by the number of distinct high-stakes endeavors an individual patient is exposed to at each encounter. ("Just Do It!" doesn't "do it" for this crowd.)
• The complexity of human beings is such that deviating from a standard approach to accommodate a physiologic, social, or cultural variation is often necessary. (This doesn't mean that standard operating procedures never work or shouldn't be used to form the scaffolding of patient care.) Since every eventuality cannot be tightly defined and scripted, teaching frontline clinicians the principles that inform safest practices allows them to recognize risk points when they must deviate for cause. Safety-knowledgeable clinicians are able to make adaptations that uphold core principles of safest system design. (This is another incarnation of the "teach them to fish" parable.)

I write a quarterly column about patient safety for Medscape, a robust continuing education platform. The most recent column, From Safe Practices to Safe Patients: The Evolution of a Revolution provides an overview of where the discipline of patient safety has come from and previews what's next.

It's an easy-read, no matter where you are along the journey.

Patient Safety & Social Media: This dog can hunt!

Fabio Gratton, over at Ignite Health, did a fantastic thing by aggregating the tweet feeds of the top 25 Patient Safety tweeps I identified in last week's inaugural listing. You can access real-time information from people who have something to say about patient safety 24/7 by clicking here: The Patient Safety 25.

Patient safety is a discipline that sounds more like a warm puppy than a scientific approach for solving a serious public health problem. So harnessing the power of social media to make high-end patient safety endeavors more visible is a welcome step for those of us who walk the big dog.

Here are FAQs about the Top 25:

Who are these tweeps? And why are they here?

Patient safety tweeps come from 4 categories:

1. the experience of patients and families

2. the people and processes that touch them (clinicians, care settings, work flow design)

3. organizations where care is delivered (how resources are allocated, leadership exemplars, what's valued & rewarded)

4. other stakeholders (regulators; accreditors; payors; patient safety organizations; pharmaceutical & device manufacturers; researchers)
   

What makes for a high-end patient safety tweet?

It shares something about or leads people to: effective strategies and resources that reduce error and help shape performance of systems and the people who use them (to receive or deliver care). Errors & near-misses, examples of open disclosure, improvement strategies, outcome measures, technology solutions, and "a day in the life of" accounts written by patients or clinicians frequently yield high-end patient safety information.

People who are effective patient safety advocates borrow from cognitive psychology, systems engineering, and human factors, and they recognize the inherent fallibility of humans. (Endeavors that "blame, shame, and re-train" don't usually make the cut, but they're worth knowing about and tracking since they also shape culture and performance.)

How often is the list updated?

Monthly, around the 15th. The Twitterverse is new, and there are tons of high-end patient safety endeavors beginning to migrate there. I'll be on the lookout for new ones and will include them as their tweeps begin to make an impact.

How can I make a patient-safety tweet more visible?

Use the hashtag: #ptsafety. This makes it more likely that a patient safety-sensitive tweet will be picked up, evaluated, and passed along.

Safety Nurse's Top 25 Tweeps for Patient Safety

Patient safety is a healthcare discipline that takes a critical look at how well intention meets outcome. It's one of the six key dimensions of quality described in the IOM reports that first quantified how often people are harmed as a result of seeking care, then outlined improvement strategies. The other 5 dimensions are: effective, timely, patient-centered, efficient, and equitable.

Broken down to its simplest, patient safety doesn't cure cancer. It exists to be certain that no one dies as a result of a chemotherapy overdose.

The systems used to deliver care and the culture of the organization where care is provided influence how often inadvertent harm occurs. Transparency, disclosure, error reporting, and an urge to prevent errors by learning from 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. They use proven strategies that mitigate the consequences of human error. Like other worthy endeavors, this one is realized with high-end metrics, and, like others, patient safety relies on IT solutions.

That said, my Twitter network is comprised of consumers, patients and professionals, all of whom value patients and their safety. The healthcare dialogue on Twitter is rich, and the perspectives and causes diverse.

Today's list allows me to share 25 tweeps I've identified as valuable patient safety resources, visionaries, or exemplars; their approach is consistent with the science of patient safety and they're currently active in the Twitterverse.

In keeping with the spirit of Twitter, I'm using only 140 characters to share why I follow each one.

1. @dirkstanley Hospitalist, CMIO. Prolific tweeter, excellent networker. Watches healthcare, strategic.
2. @ePatientDave Has a dog in many dimensions of the fight to improve healthcare. Gives new meaning to transparency. Rock on, Dave.
3. @ecri_anderson Editor of ECRI Institute's risk management & pt safety publications. Tweets make high-end PSO info widely available.
4. @IHIOpenSchool An interprofessional educational community giving students in health professions skills to change healthcare culture.
5. @INQRI Does research to understand how nurses contribute & improve the quality of pt care. Frequent #patientsafety sensitive tweets.
6. @ismp1 President of ISMP, a nonprofit, multidisciplinary, drug safety agency. A wealth of knowledge & practical med safety tools. Unflinching advocate.
7. @JCommission A not-for-profit organization, TJC accredits, certifies health care organizations. "Aligns & defines" pt safety standards.
8. @jfahrni Pharmacist, infomatics. A good barometer for how it's hitting the frontline. RTs high-end stuff & not afraid to push back.
9. @jkfaw Parent-founded collaborative, bringing providers & patients together to create a culture of safety. http://bit.ly/xDWdr
10. @JohnSharp Infomatics research. HIT should be the great patient safety enabler, a window into how it can work. More, please.
11. @JustinHOPE Parent founder of children's patient safety org. Determined advocate for transparency: http://bit.ly/DeptR
12. @medusesafety Tweets from the American Society of Medication Safety Officers. Leaders in a high-stakes, interdisciplinary milieu.
13. @midwifeamy Advocates for safety in birth and offers wise counsel, "Don't fix it if it ain't broke." http://bit.ly/jJX0i
14. @MissMedSafety Seasoned clinical nurse & med safety expert in the trenches every day. Lives it & finding her voice in the Twitterverse.
15. @NPRhealth Follows it all. If it's big, they'll have it and link to high-end analysis. Not for those looking for a Happy Meal.
16. @paulflevy Healthcare CEO. Models transparency, leader engagement. Blog worth daily read in busiest schedule. http://bit.ly/pkMaO
17. @pharmaguy Knows his mission & how to tweet to accomplish it. Gets around and says the hard things. Needed. http://bit.ly/4zGV0z
18. @PSadvocate Patient Safety perspectives by a non-clinician, exposed to process improvement tools OTJ. Finds & RTs are credible.
19. @PSeditor Editor HCPro, Inc. Fosters patient safety engagement. Nurtures, networks effectively using 2.0.
20. @quantros PSO, tweets to improve patient safety & reduce medical errors in the US healthcare system. Often prolific & always on target.
21. @sevinfo Pharma/Biotech information researcher, librarian. Voracious reader & mom has a good eye for safety sensitive stuff. Authentic.
22. @SusanCarr Editor, Patient Safety & Quality Healthcare magazine. Just plain gets it. Plus her info is readily accessible online. A find.
23. @tully3000 Excess med mal claim manager. Keeps an eye on all things healthcare & reliably separates the wheat from the chaff.
24. @WSJHealthBlog Not patient safety only, but some of the best stories there. Check regularly. When it's there, look for more coming.
25. @writeo An ex-editor at The Oregonian; now 1 of 2 consumer members of OR Pt Safety Commission. Tweets & RTs big picture info to broad base.

Thanks for updating your patient safety tweeps. The main problem with making this list is that the patient safety community isn't as visible as it could be and the list is way too short. Keep in mind that many highly credible patient safety initiatives and individuals haven't yet made it to Twitter, so check back often to update your follows.

If I missed you or one of your #patient safety favs, leave me a comment so I can adjust my filters or begin following you!

For Dale Ann & Sorrel: A Labor of Love

Having spent many years as a perinatal nurse, I always wind up thinking about mothers on Labor Day, reflecting on the incredible work that's just beginning on the day a baby is born. So I was taken back today when I found a link to Modern Healthcare featuring patient safety advocacy by mothers who have lost children as a result of medical error. And remembered that Sorrel King's book, Josie's Story, would be published tomorrow.

These are labors most painful.

Visit the Modern Healthcare site and read Sorrel's book anyway. You'll see my friend Dale Ann Micalizzi on the cover of Modern Healthcare. I met Dale Ann through Twitter, Facebook, and shared connections in the patient safety world. She graciously recounted her family's story--one that includes a non-profit pediatric patient safety organization named for her late son, Justin--for an article I wrote last month. More about Dale Ann and Justin's Hope will appear in the Medscape article that's in press.

Sorrel King's daughter, Josie, was just a toddler when she died at Johns Hopkins Hospital in 2001. Sorrel has become a tireless patient advocate advancing Rapid Response Teams and processes that maximize patient and family involvement when clinical conditions worsen. A post I wrote last week, Before there were Rapid Reponses Teams.... came in response to a call put out by The Josie King Foundation asking more families to share their stories.

Today, Dale Ann, Sorrel and others continue the tradition of laboring on behalf of their children. Only this year, and for all the years to come, their efforts will help other families avoid the circumstances that harmed their own.

We all need to take a deep breath. And push.

Baby steps

Today, Hearst newspapers published a series of reports, Dead by Mistake, about how often people in the United States die as a result of seeking healthcare. It's a big number.

98,000.

The same number--widely seen as an underestimate--that's been floated for the past 10 years when the first comprehensive national report on patient safety was published. Today's Hearst piece added an updated comparison (in the event that comparisons to deaths from AIDS; breast cancer; and auto accidents are insufficient for illustrating the magnitude of the problem). In one month, more people die as a result of medical errors and healthcare acquired infections than died on September 11th. For the record, these iatrogenic events continue to kill more people than AIDS, breast cancer, and auto accidents. Combined.

One article published the Albany Times Union provides an excellent recap of where key improvement measures, recommended nearly a decade ago, stand today. It's worth a read whether you're a seasoned observer of medical misadventures or are just beginning the journey.

I'm in the "seasoned" crowd, and there's something in the Hearst reporting that, while not progress in and of itself, may at last be signaling change, paving the path where progress will ultimately travel.

The piece is amply illustrated by the tragic stories of individuals whose lives have been lost or forever changed as a result of medical error. The profound feelings of grief and betrayal experienced by affected individuals hasn't changed, and won't change, until there are no more stories to tell. But what does seem to be changing is a shift in perception about where the opportunities for improvement rightly lie.

When the public demands and institutions support the notion that individuals can be made to perform flawlessly, progress--in any endeavor--is stymied. Individuals can never be flawless, and from a mathematical standpoint, the performance of individuals organized within a system can't be made flawless either. But the odds of disaster when individuals work within well-constructed systems can be reduced to a near-negligible point. This is a guiding principle in industries, such as commercial aviation and nuclear power, that reliably produce an intended, and expected, result.

The Hearst report is rife with criticisms, rightly centered on infrastructure and process defects. High-end individual performance by front line clinicians can only be predicted to occur, and reoccur, when seated within work processes designed to, well, work. The report is noteworthy in its mention of such things as:

• negative consequences arising from a decade-long failure to establish a comprehensive, nationwide error-reporting system
• how a lack of organizational transparency hamstrings patients, as pure consumers of care and in the aftermath of an adverse event
• the consequences when hospitals make full adoption of NQF's Safe Practices a low-priority item

Focusing on system weaknesses means giving up the idea that a Sam Smith, RN or a Jo Jones, MD killed someone (and 97,999 other someones every year). It looks instead at what's available when one Sam or one Jo isn't up-to-snuff, up-to-speed, or up-to-date, and builds a system that allows patients to survive when human fallibility is unmasked.

If a journey of a million miles begins with a single step, we may have seen the first one taken this morning in the Albany Times Union. And we'll soon see if the baby really can walk when we see how patient safety is prioritized in the healthcare reform we're about enact.

I'm so very sorry

Tomorrow is National Patient Safety Day, a time to remember people who have been harmed while seeking care or cure. It's also a time to consider how people--patients, providers, and those who have been or will someday be patients--can improve the care delivery system and eradicate preventable harm.

Patients are infrequently the target of professionals who intend to harm them. But people, millions of them each year, are nevertheless harmed. I'm sorry for preventable harm that has occurred and sorry for preventable events that loom.

I was a hands-on clinical nurse for a long time. I don't think I've been the last person in a chain of events that resulted in harm to a patient. But I could have been, any healthcare provider could be. Clinicians frequently fly without safety nets, and it's often grace--not structure or safeguards that come when hearts, minds, and wallets open to achieve and sustain reliable processes--that distinguish clinicians with pristine records from those who err. I'm sorry for errors I may not have seen, known to report, and for near-miss events I didn't see as valuable in the fight to eradicate errors.

This morning, it didn't take me long to find a credible account detailing what patients and front line clinicians face each day. In A Nurse's Very Bad Day, New York Times health blogger Teresa Brown, leaves readers with an unflinching picture of what good people who work in, and depend upon, our well-intended but unreliable system regularly face. I'm sorry that a strong, competent nurse cries like a soldier at the end of a battle in civilian territory. I'm sorry for the risks her patients face.

The answer to how millions of people are harmed from preventable medical errors each year lies in all the tiny details that went wrong in Teresa's Brown day. These answers are not easy, cheap, sexy, or full of star power.

People, like me, who are sorry about the harm that has occurred--particularly those who seek to reform healthcare--should harness this sorrow and transform the system into something that's not so regrettable.

In the meantime, let me just say: I'm sorry. I'm so very, very sorry.

California is full of bad actors

California is full of bad actors. But maybe I should tell you something you don't already know.

In case you missed it last week, California's Governor Schwarzenegger replaced most members of the State Nursing Board. This action followed an LA Times report detailing the board's inability to evaluate and rule on allegations of professional misconduct by registered nurses in a timely fashion. A day or two later, two California state senators announced they were crossing party lines to author legislation that would reform the state's Medical Peer Review process. Both actions were widely reported under headlines forecasting improvements in "patient safety."

These initiatives--and others focusing on the processes used to evaluate and re-evaluate professionals who may be "bad actors"--are indeed part of the fabric that protects the safety of patients. But equating occasional long reaches down a dark foxhole with "patient safety" is a huge disservice, a distraction almost, relative to what the science of patient safety really is and what it takes to get the job done.

Patient safety is really the science of reliability applied to healthcare: How does a system operationalize processes in order to achieve a stated goal? It's not "How to cure cancer?" but rather, "How do we ensure that a patient is not killed by an overdose of chemotherapy while undergoing treatment to be cured of cancer?"

Goals like these rely on competent individuals, but they are not achieved--in a reliable fashion--solely because of them. (Having a sober pilot does not guarantee a safe flight.) Measures that focus on individuals' performance and behavioral choices should not be equated with the full spectrum of activities needed to improve the reliability of healthcare.

As healthcare reform ramps up, patients and professionals should be looking for measures--and funding--to enhance patient safety that are wider than a foxhole and constructed in a way that allows existing tunnels to connect.

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.

Patient Safety: Is it really like baseball, hotdogs, apple pie & Chevrolet?

Happy Patient Safety Awareness Week! We're at the tail end of the nation's weeklong campaign designed to spur conversation amongst consumers and providers and promote strategies to make patients safer.

I don't know what the celebrations look like where you are, but most people I know are talking about worrisome first quarter financial projections, rising unemployment, and the possibility of many more people joining the ranks of the uninsured. It's exceedingly tough to be an effective advocate for patient safety these days, a concern reflected in the theme chosen by the National Patient Safety Foundation for their 2009 spring meeting: "Patient Safety in Challenging Times: Now More Than Ever, a Critical Need."

I've found that Wikipedia entries often offer simple words that capture complex ideas, so I tooled over and was happy to find this definition at http://en.wikipedia.org/wiki/Patient_safety:
"Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often lead to adverse healthcare events."

Thank you, Wiki, for a step in the right direction. Because it seems to me that part of the "patient safety" advocacy problem may be rooted in its warm, fuzzy name. "Patient safety" sounds like a simple "mom and apple pie" issue. I'm for it! You're for it! We're all for it! Who wouldn't be for patient safety?

(Just for fun, picture yourself, a colleague you respect, or your personal physician in a very public forum--let's say "on the news" or "under oath" to set up a visual. Now imagine the question, "So, do you or do you not embrace patient safety?") There really is only one right answer.

But can everyone who can honestly say, "I'm for patient safety," also say, "I'm committed to a process in which real or potential error is reported and deconstructed, where failure points are identified, and, when necessary, to the redesign of work processes to prevent recurrence of an error or event"?

Really being for "patient safety" requires more than good will, a caring heart, or a pledge to "do no harm." In order to diminish inadvertent harm, seasoned clinicians have to examine, and sometimes leave behind, elements of dearly-held, intention-based beliefs and practices. ("The Five Rights" may not make it through process mapping and meticulous work flow redesign.)

In the end, these clinicians, whose valuable expertise arose in a different tradition, will likely adapt processes and methodologies, borrowed from high stakes industries with superior safety records. A new generation of "digital natives" will join our ranks, bringing new norms and new ways of taking on and solving complex problems. Reliability in healthcare will improve. But this is a process, not an event.

To answer, "Yes, I'm for patient safety," healthcare managers, administrators, and payors must embrace the emerging science that informs safety, invest in high-yield products and processes, and nurture widespread culture change. Again, a process, not an event.

Investing in better processes is still investing, and "patient safety" may be a hard line item to defend in a tough economy. So as National Patient Safety Week comes to a close and the inevitable rounds of budget cutting begin, I hope I've left you with a user-friendly assessment tool. Just ask, "Are you really for patient safety?"

Stay safe and come back soon!

Welcome to Florence dot com

I find inspiration, and occasionally wisdom, in unexpected places, and I hope you'll find some here at Florence dot com, a place for people interested in improving healthcare.

A few months ago, I happened upon a documentary about a senior citizens chorus from Northampton, Mass called Young@Heart. In it, an octogenarian suffering from congestive heart failure sings a rendition of "Fix You," a Coldplay song about learning from mistakes and fixing broken things, which drew critical acclaim for the chorus (plus hundreds of thousands of hits on YouTube and other sites that linked the clip in the fall of last year).

Even if you haven't seen Young@Heart or a clip of "Fix You," I'm certain you know someone like Fred Knittle. He's been in your ER, on your inpatient census, or on your patient roster. And you probably saw him at the Walmart a time or two. To me, Fred Knittle's rendition of "Fix You" says more about healing--and the valor of persevering--than anything I've bumped up against in a very long time. The message hits home, maybe, because Knittle is backed up by his portable oxygen tank as well as his loyal choral compatriots. Or the meaning intensifies because Knittle sings his part and the part of his partner, a fellow chorus member who passed away just days before the piece was filmed. Or maybe it's because Knittle's remarkable baritone croon may not have anything to do with fixing at all.

The thing that I most love about the success Knittle enjoyed is simply that it came at all (he died on New Year's Day in '09). Knittle, if his cheerful optimism and wry accounting is predictive, lived a good life. His obituary shared events and accomplishments that evidence a life well lived: a devoted wife, children and grandchildren, military service, a long career in service to others, a loving, connected community. But it wasn't until Knittle's final years, most probably after receiving a terminal diagnosis, that he returned to a community singing group he loved and produced work that is making people around the world pause for a moment and think, really think, about what it means to care, to heal, to try, and to die.

Renewal coming from a broken place speaks to me. In the healthcare industry, we frequently produce an outcome we did not set out to achieve, making our work, from an engineering perspective, well-intended, but not reliable: in the US medical errors are the 8th leading cause of death. Each year, more people die as a result of medical error than die of AIDS or breast cancer. We are broken.

What ails healthcare is not a "one person" or "one profession" problem nor will the fixes be singular. Healthcare professionals, like the Young@Heart chorus, may appear too old, too tired, too exasperated, or too out-of-breath to always look like credible sources of hope. Fred Knittle didn't look the part either. While most performance problems in healthcare are rooted in our systems, that is, how we do business, solutions ultimately rely on what people come to view as important and how we adapt. I hope you'll return regularly to Florence dot com for cues, clues, and commentary about cutting edge trends in patient safety and that you'll find this a good place to share your insight and experience, whether you're a professional, a consumer, or both.

"Lights will guide you home and ignite your bones, and I will try, and fix you." Thank you, Mr. Knittle.