How we respond to error

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

Participatory Safety

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

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

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

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

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

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

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

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

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


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

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

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

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

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

Honor the Game

One of my favorite books is Made to Stick by Chip Heath and Dan Heath, brothers who tell interesting stories about why some things capture our imagination and others leave us cold.

A Made to Stick story that stuck with me is how coaching leader Jim Thompson drove down the incidence of bad behavior in youth sports. Thompson started by recognizing "be a good sport" was an insufficient call to action. It wasn't a strong message, and more importantly, the charge didn't improve the conduct of youth players, coaches, parents, or spectators. So he refocused attention away from the individual to something larger, the game. Thompson called his campaign "honor the game" and illustrated it with some powerful examples, like this one:

Lance Armstrong once slowed during a Tour de France race to give his chief opponent, who had crashed, the chance to get back in the race. As his opponent remounted, Armstrong paused rather than taking full advantge of the lucky break, later noting that he rode better against strong competition. Armstrong wasn't "being a good sport." He was honoring the game.

Redesigning healthcare is about honoring the game, making it possible for the actions of individuals to contribute, in measurable ways, to something larger. The healthcare industry, and more importantly, the processes used to deliver healthcare, are under scrutiny. They should be: more people die in the US every year from preventable medical errors and healthcare acquired infections than die of AIDS, breast cancer, and auto accidents, combined.

"Honoring the game" requires a different style of play than Nike's more familiar call to action, "Just Do It!" (at least in the beginning stages of the race against harm-causing errors). Here's why:

For some time now, system design and human factors experts, dispatched from high reliability industries like commercial aviation and nuclear power, have partnered with healthcare workers to find out what ails us. Early on, industry outsiders recognized something important: When compared with other industires, the systems healthcare workers relied on lacked standard engineering controls, key elements needed to make intention match outcome. (Standard engineering controls include such things as barriers, redundancies, and opportunities to detect and mitigate errors that have been set in motion).

In commercial aviation, high-stakes tasks that could cause harm if performed incorrectly are never executed by just one person. There's always a double check. In fact, these process checks are mandated by law. Compare this norm with what a nurse (at least in the era when I came of age as a clinician) may be expected to do in a busy Emergency Department: take a verbal order, retrieve a medication from a large cache, calculate the dose, prepare the medication, and administer it to a patient. This process could be the norm irrespective of whether a drug (like Lasix) has a small chance of causing harm if used in error or whether harm is highly likely if an error occurs, as is the case with IV heparin. No barriers, no redundancies, and scant opportunity to detect an error that's been set in motion.

A commercial pilot would never fly using the type of safeguards most nurses have been taught are reasonable for caring, competent professionals to use and execute flawlessly, even under the most hostile conditions.

Industry comparisons will not take us the whole way on the journey toward reliability. But industry comparisons help dispel myths, some of which healthcare workers may find painful. The good news is that nurses, pharmacists, physicians, and others who work in healthcare are not inherently more eror-prone than the professionals who maintain airplanes, fly them, or control air traffic. The bad news is that we're not less prone than others to screw up either. And how much a professional understands or cares about a process, an outcome, or an individual patient may not be as important as many of us intuitively believe.

To honor the game, a player has to have reasonable chance of being successful. When my son was young, he had a computer baseball game that allowed him to select teams, take the field, and play virtual games. Luke's team always won because he put himself on the team with Sammy Sosa and Mark Mcgwire. (The opposition in his fantasy game usually had a few bookish kids with their shoe laces untied and, as I recall, a little girl with broken glasses on crutches.)

In the real world, we need to make certain people stand a chance of executing the tasks we expect them to do. This is the reason nurses, and other front line healthcare professionals, should pay attention to system design and speak up when expected outcomes can't be delivered without a work-around. Look for appropriate barriers, redundancies, and opportunities to recover an error set in motion. A good place to start is to think about how you identify patients, have medication orders reviewed, store drugs, and take verbal orders. The "a-ha" moments will follow.

Really. Just do it.

Note: My undertanding of human behavior, performance-shaping factors, and system design is highly influenced by the work of David Marx, President of Outcome Engineering and the author of the Just Culture algorithms. Dave and others from OE have generously shared their time and expertise to help me learn more about "the science behind the compliance" in patient safety. I encourage you to visit the Just Culture website and read Dave's book "Whack-A-Mole: The Price We Pay for Expecting Perfection" to learn more.

Feeling Silly Saturday

I have a second blog that sits on Medscape's platform. It's a forum where I share medication safety strategies with professionals, and I named it On Your Meds: Straight Talk about Medication Safety. Comments left at On Your Meds are always interesting, often enlightening, funny, and sometimes sad. I think what nurses share there says a lot about the fitness of the systems we use to deliver medications.

I joke that I should have a blog called "Get On Some Meds" or "Stay On Your Meds." Apparently, someone has been listening.

Comments at On Your Meds usually pop up in the week I post something new. So I was surprised to receive a series of notices showing new comments on an old post, entitled, hmmmm, "Not exactly the language of love: Words to identify and prevent errors."

Since error-reporting is a guiding tenet of safety engineering, I thought it might be useful to let others know what happens when you include the words "language of love" and "medication" in the most searchable elements of electronic media, which appears to be the error I made. Can you say "erectile dysfunction spam"?

Unfortunately, none of the cheap generic sildenafil and tadalafil spam I cleared the other day were as amusing as this:



Oh, and by the way: This is not a product endorsement. It's advice about managing a blog. I don't give medical advice, and you should consult a healthcare professional for any problem you might have, including an erection lasting longer than 4 hours. You can find standard safety information about tadalafil and sildenafil here and here.

What really burns

Mentioning that I was the recipient of a hot coffee burn at the drive-thru where I am a "regular" is embarrassing. Following the widely publicized case in the mid 1990's, the topic of "hot coffee burns" has been a polarizing topic. I try to stay away from issues like these, being more of a lover than a fighter in the war about what--from an evidenced-based standpoint--actually makes people safer.

But since the coffee actually fell into my lap on Saturday morning, I'll take it as a sign that I'm supposed to say something about the issue of human error and organizational response as it relates to the potential for hot liquid to spill on people who choose to purchase these products in a drive-thru.

I noticed that the lid to the cup on my coffee was slightly askew when I removed it from the drive-thru shelf where the server had placed it. I thought I could reseat it myself since the visible defect was only a 1/2" rise in what appeared to be an otherwise good seal. Unfortunately, what I would represent as gentle pressure downward on a paper cup not supported by anything except my left hand caused the cup to change shape. The lid popped off and nearly half of my large brewed coffee, with cream, hit my right thigh. It felt really bad for a few moments, the kind of bad that makes the back of your throat ache as the acute pain subsides.

The server on duty on Saturday frequently prepares my morning coffee, and the lid has always been placed correctly in the past. As I struggled to get myself back together and finish the transaction, she passed me napkins and gave me a new cup of coffee, appearing somewhat distraught. I'm thinking this is pure human error. A human will not seat a lid correctly 100% of the time. A customer may not know that the obvious corrective action of reseating a small defect will cause the cup to go askew and the coffee to spill. So I'm thinking it would be helpful for customers to know that it's safer to let the server fix a poorly seated lid than mess with it in the car. Maybe a sign in the drive-thru window saying something like, "If you notice the lid on a hot beverage is crooked, please let us fix it for you." I live in an area where a lot of people speak Spanish. So maybe the sign should be in both English and Spanish.

Since the server is a pleasant young woman and she looks kind of worried, I say to her, "I'm not interested in suing over a hot coffee spill here. But I am interested in making sure this doesn't happen to someone else." That's when she replied, "Oh, well it happens all the time. You should have seen the last lady- it was an extra hot cup of tea. We've been having trouble with these lids for awhile."

"Have you shared that with your manager?" I ask. "Oh yes," she replied. "They know all about it."

On Sunday, I return for my morning coffee. A different server is on duty. I mention the Saturday spill to her as I go through the drive-thru. I'm wondering if the cup problem is as widespread as Saturday's server had implied or if she may have felt more individually culpable than I had intended. She confirms the cups have not been performing well and that "the company" is trying to get better ones.

The red spot faded in a few hours, I have no compelling reason to revisit this issue. Except I know that by reporting a problem, reasonable people can take steps to prevent the problem from reoccurring. Customers can try to be more careful. You can hang a sign to point out risky conditions that can't be minimized in other ways. But those are low level risk-reduction strategies. Here's a more effective way to prevent burns: Cups that hold hot liquids should have lids that fit. They should be able to be manipulated into position by average workers and passed through the drive-thru window with a very low failure rate, if a business chooses to sell hot liquids in this fashion.

Sunday's cup was defect-free. And today's cup is fueling this post.

I'm just trying to help prevent someone else from getting burned.

Risk points across the medication use system

Recently, Nurse Ausmed shared a great post about an intervention that lessened the likelihood of an IV medication error occuring in a pediatric patient. Her take-away lesson was "simplify, simplify," a core principle in safe medication practices.

Earlier this week, I wrote that Nurse Ausmed's online case study would lend itself to a basic excercise in identifying the latent (or upstream) conditions that often lead to error on the front line. Links to ideas about modeling human error (developed by James Reason) and some online pediatric medication safety resources were provided.

Here are my initial thoughts:

To answer the question, "Could the error-prone condition be identified and the potential for patient harm lessened before it reached the front line?" start by considering what the medication use system looks like:

The roles and responsibilities of professionals ("who does what, when, and how") may vary according to practice setting and applicable professional standards of care. Irrespective of setting, however, prescribing, transcribing, dispensing, administering, and monitoring are the units, or nodes, that make up the medication use system.

It's important to pause for a moment and take this in. As individuals, we typically focus on the portion of the system where our own professional duties lie, rather the system as a whole, making it difficult to see upstream opportunities.

Now consider the problem of errors in the medication use system:

Errors may originate at any point in the process. In the slide below, the red arrow illustrates how an error that began in the prescribing phase is not picked up, moving through all downstream defenses to reach the patient.

Seminal medication safety research shows the likelihood of catching (and correcting) an error increases the further upstream the error originates. This makes sense since an error in the prescriber's order has the potential to be picked up by the person who dispenses the drug, the person who administers the drug, or the patient. This is why processes like independent double checks and automated clinical decision support are valuable: they make errors and error-prone conditions visible before they reach the patient.

Unfortunately, errors that originate in the administration phase are highly unlikely to be picked up before they reach the patient. This is why processes at the point of administration should be as simple, standard, accurate, and dependable as feasible. (I think of clinicians who administer medications and the processes they use as I would a flight crew: it's probably not a good idea to expect problems to be solved at 35,000 feet that could have reasonably been resolved on the ground or to use patchy processes to accomplish high-stakes, in-flight tasks.)

Later next week, I'll come back to this topic, using clinical information Nurse Ausmed shared to help identify strategies for preventing IV medication errors in peds that are on the high end of the risk reduction hierarchy. I'd hope you'll share the risk-reduction strategies you use when you care for pediatric patients.

Stay safe and come back soon! I've been thinking about something I heard Paula Poundstone say last week, and the next time you check in, you need to be ready to laugh!

Fishing in a well-stocked pond

Florence has a sister, a new blog on the Medscape site called, "On Your Meds: Straight Talk about Medication Safety." I hope you'll take a look, and bookmark the site because On Your Meds is going to host a running commentary on specific strategies for reducing medication errors.

The current post is about high-alert medications, those with a heightened risk for causing harm if used in error. Insulin, chemotherapy, narcotics, drugs with weird dosing schedules, drugs with impossibly narrow therapeutic indices, drugs that result in closure of life-sustaining orifices if halted by mistake..... Let's just say that the drugs on ISMP's High-Alert list have earned their place.

I spent a year studying medication error prevention with ISMP, the nation's foremost experts on the subject. So I know more than the average bird, and often more than I wish I did, about medication errors. But you probably do, too: A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.

People often wonder where I get the stories I use to illustrate key facts about med safety. Med errors can arise anywhere in the medication use process, a complex system (run by human beings) that includes: prescribing; dispensing; administering; and monitoring the effects of drugs.

Now consider that in a given week, an average of 82% of adults in the U.S. are taking at least one medication (prescription or nonprescription drug, vitamin/mineral, herbal/natural supplement); 29% are taking five or more. (These stats provide a snapshot of adults in community settings and exclude medications administered to people in hospitals and extended care facilities.) At this point, the stories find me. Or as Larry the Cable Guy might say, "You're fishin' in a well-stocked pond, sister."

Last week, I'm in the locker room at the YMCA, sharing a little more personal space than I'd rather. I've just finished cycling, and it looks like the Y member closest to me is preparing for "Twinges," the water class for people with joint disorders. She's chatting with a friend, and putting her clothes in a locker. The next thing I know, a bunch of pills, maybe 12, have spewed from the pocket of her balled-up Khaki pants. Some hit the bench, some the floor, and a few land in my gym bag. I help her retrieve them, phrases like "drug storage" and "mindfulness" flashing in my brain. She scoops up the last visible ones, examines her catch, re-pockets them, and says to her friend, "Good, I got the yellow one. We can still go to lunch."

I'm working on a project about insulin pens, visiting the manufacturers' Internet homepages and checking out the patient education materials available there. I notice images on a manufacturer's site where hip-looking teens are depicted using their insulin pens as hair accessories. Phrases like "drug storage" and "mindfulness" flash in my brain.

ISMP shares an error analysis in which a patient being treated for angina in a busy Emergency Department receives IV saline instead of IV nitroglycerin. The commonly used nitroglycerin is seated next to a similarly-appearing, but obsolete, glass bottle of 0.9% sodium chloride. The key elements? "Drug storage" and "mindfulness."

Across the continuum, themes repeat. I'll be reflecting more about them here at Florence dot com and at On Your Meds. In the meantime, it may be worth thinking about the utility of high-level risk-reduction tools. Should professionals use the same strategies to manage medication risks that senior citizens at the YMCA do?