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.

I'm @SafetyNurse. Fly me?

Over the past decade, healthcare has borrowed a number of engineering strategies widely used in commercial aviation to improve safety. Barriers, redundancies, and opportunities to uncover errors inadvertently set in motion are increasingly used to help prevent patients from "going off the runaway."

In the aftermath of the US Airways flight that safely landed a planeload of people in the Hudson River earlier this year, a pilot's words about the investment the flight deck has in safety stuck with me. "We're first up and last down on every flight." His words resonate because they so clearly align with a jet's nose-up take-off and wheels-down landing, an image indelibly etched in my mind after flying hundreds of thousands of miles.

We don't have reinforcers like that built into healthcare. But there are signs that the stakes are going up for leadership engagement in patient safety. Last week, The Joint Commission issued a sentinel event alert describing safety-sensitive beliefs and actions required of leaders--many that challenge healthcare's historic "Just Do It" approach to safety.

The Joint Commission's bulletin stresses the importance of matching what leaders say is valued with what's visible to front line professionals during routine and high-stakes junctures of care, particularly in the aftermath of high-profile error. Once again, we'll be borrowing from aviation.

So here's a nod to modeling transparency, an essential element of a culture of safety. I'm @SafetyNurse. Fly me!

First responder at 35,000 feet: The value of a good book

A few years back, I took a flight to Philadelphia to interview for the Safe Medication Management fellowship at the Institute for Safe Medication Practices. I was using the travel time to skim through "Medication Errors" (2nd edition), a book written by people I would meet the next day. Seated in an aisle seat, I had the iPod going full tilt, a distraction that both blocked airplane sounds and helped settle the butterflies in my stomach.

I may have been aware of some peripheral commotion but didn't really pay attention until a flight attendant, who had apparently noticed the title of the large textbook on my tray table, tapped me and asked, "Are you a medical professional? There's a gentleman on the plane who thinks he may be having a stroke. Are you willing to help him?"

I'm a perinatal nurse. Placentas. Labor. Birth. High-stakes vascular events in my clinical world are nearly always preceded by the diagnosis "pre-eclampsia," something a male simply cannot get. "Sure," I said, struggling to put on my shoes. "Stroke, stroke," I thought as I lumbered toward the designated seat. I think I should say something like, "What makes you think you are having a stroke, sir? Does something feel numb? Are you having trouble moving?"

When I reached the gentleman, however, talking was out of the question. He was cold, clammy, unresponsive, with a thready, bradycardic pulse. Where I live, people call this condition, "fixin' to die."

The flight attendants, working from a checklist, had notified the captain and sought help from medical personnel amongst the passengers. Communication with medical experts on the ground were being facilitated (loudly, with assessments and observations called from one flight attendant, stationed near our passenger-turned-patient, to another flight attendant, stationed at the now-open cock-pit door).

We apply oxygen by tight face mask. The first responders are three: me, an ex-Army corpsman, and someone who declines to be identified, although he is able to get oxygen flowing. (Something that's useful to know if you're a first responder while in flight: they don't drop the oxygen from the over-seat compartments. That's for emergencies that impact the oxygenation of everyone on the plane. Your team will be given a portable oxygen tank, and it may be helpful to remember "lefty-loosey, right-tighty" once you locate the on-off valve.)

"I have an AED, ma'am, I have an AED," the flight attendant repeated, rather persistently, pushing the box in my direction. Still feeling a pulse, but he's grayer, and the pulse rate is lowering. "Think, think," I thought. (The image of defibrillating a large man, mid-cabin just couldn't take hold in my mind. All I could picture was the impossibility of saying, "I'm clear, you're clear, we're all clear," when 5 rows of passengers are sitting in the metal chairs this man is going to touch if we lay him out here.)

Meanwhile, there's more flight attendant-to-cockpit communication (okay, yelling) as preparations for flight diversion are considered in light of the passenger's grave condition. "Does he have any medical conditions? Heart disease, diabetes,....." came the question as the flight attendant moved down the checklist. His traveling companion looks up, gasps, and says, "He has diabetes." Sweeter words had never been heard. This was something a perinatal nurse could do something with.

"Sugar," I said to the flight attendant. "Bring me sugar from your cart." The gentleman was unresponsive but the table sugar, which I applied (er, jammed) rather unceremoniously under his tongue and moistened with a few drops of water made him come around right quick. (Something else that's helpful to know if you're a mid-flight first responder is that flight attendants have a checklist and their efforts work in tandem with any assistance you can offer. The checklist helped to get useful facts, like this gentleman's diabetes, uncovered rapidly. This information would have been used by the medical professionals on the ground if I hadn't been able to put the pieces together and initiate corrective action. The take-away lesson? Help may not be as far away as it initially feels at 35,000 feet.)

It turned out that the passenger was a relatively new diabetic, and the day of traveling had put him off of his normal eating routine (although he had remembered to take his medications that morning). We continued on to Philly, with the gentleman refusing the EMS care that met him at the gate. I waved to him at the baggage claim area, and told his companions that he really should seek follow-up care immediately, something I very much doubt he did.

At my interview at ISMP the next day, I was asked if I had had a good flight. Of course, I told the story about the book and the in-flight interventions, at which point one of the staff members said to Mike Cohen, ISMP's president, now my mentor and friend, "See Mike, the book saved another life." Probably true. (I learned a great deal of life-saving information when I actually read the book, and I highly endorse it, both for its intended purpose and any adjunct benefit it affords the traveling public.)

May you always have a good book and fly the friendly skies!

Materials in this post first appeared on my Medscape blog, "On Your Meds: Straight Talk about Medication Safety" in April 2009.