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.

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.

Can you hear me? Can you hear me now?

Welcome to the ongoing celebration of Nurses Week 2009, honoring nurses and nursing sensibilities. Today, it's all about hearing, and the good things that hearing makes easier, like listening and communicating.

Talking "patient safety" with nurses is like preaching to the choir, with the choir finally getting access to sheet music.

A few words about the valuable roles nurses play in making patients safe:




Finally, a look at standards and emerging best practices:

And a small musical tribute that says just a little bit about the important work you do:

Feel free to use the comments section to add suggestions to round out the playlist of songs celebrating nurses. Flo & Bo struck out in several genres, notably country and hip-hop. But hey, it's your party, you can cry if you want to.

Grand Rounds

Grand Rounds is up at Pharmamotion with an interesting series of posts about the state of health and healthcare. Anyone looking for exemplars or barriers to the Institute of Medicine's six dimensions of care (Safe, Effective, Timely, Efficient, Patient Centered, and Equitable) will find interesting things to read there today.

I'm reflecting on Nurse Ausmed's post that was included in Grand Rounds because it speaks to realities of the system front line clinicians rely on. In this post, a seasoned nurse reflects on the theme of nursing advocacy, an important component of nursing care. The touching account of how she helps young brothers prepare for the death of their newborn sibling shows the value of individualizing care, of using "teachable moments" that unfold at the bedside, of responding in ways that set the stage for healing that will occur long after clinical care ends. This is the essence of patient and family centered care.

Nurse Ausmed also shares how nurses' advocacy can make medication administration safer. It certainly did in the case she described (having the concentration of an infrequently used medication infusion--being administered to a pediatric patient--changed so that titration in mg/kg/hr would require fewer calculations at the bedside). By recognizing and responding to an error-prone condition, Nurse Ausmed makes a potential mistake that had been set in motion visible, and advocates effectively to mitigate the error-prone condition before harm occurs.

Now let me exchange my virtual nurse's cap for a safety engineer's hard hat and invite you to put one on, too. If you're new to systems thinking, and you want to learn how to analyze the error-prone conditions in your workplace, here's a real-time exercise:

• Re-read the portion of Nurse Ausmed's post entitled, "Simplify, Simplify." (She's provided a significant risk-reduction hint in the title.)


• Ask yourself: Could this error-prone condition have been identified and lessened before it hit the front line? Nurse Ausmed's efforts were stellar. She's clearly an A player (and she's at the beginning of her shift!). But I'd encourage you to identify upstream interventions--those that could reasonably be undertaken through science-based, interdisciplinary collaboration--that could have lessened the likelihood of error before the infusion reached the patient.


• Check back on Thursday to see how my analysis aligns with yours.

To help you get started, here are links to a few resources I'm going to use: James Reason's modeling of human error; ISMP's analysis of the events that led to the death of Sebastian Ferrero; cues and clues offered in The Joint Commission's Sentinel Event Alert related to pediatric medication safety; and recommendations from a multi-stakeholder group of experts convened last summer to identify ways to prevent IV medication errors.

Enjoy Grand Rounds this week, and check back here on Thursday to see principles of error-reduction at work!

Get ready to cancel the launch!

In Lessons from a Sunken Ship, I recounted the story of a 1628 shipwreck that occurred in the aftermath of a failed stability test, a test result known to at least 30 shipbuilders (who nearly put the Vasa underwater during a preliminary test of seaworthiness) and the ranking military leader who observed the aborted test. Signing off on the launch, the ranking officer lamented the absence of the King, apparently the only person with authority to cancel the launch.

This story lends itself to talking about the dangers of rigid hierarchies, and I'll probably return to it at some point, rigid hierarchies having sunk more than a few ships in healthcare. But the Vasa also illustrates principles about the hierarchy of error and harm prevention:

1. Eliminate or prevent mistakes. A better design would have prevented the Vasa from going down.

2. Make mistakes that have been set in motion visible. The ship did not perform as expected when subjected to simulated sea-like conditions. Not launching a ship with dubious stability would have prevented the Vasa from going down.

3. Mitigating the hazard should a mistake occur. Lifeboats prevented some people on the sinking ship from going down.

4. Education/re-education about how to manage known hazards. Swimming lessons might have helped some people save themselves.

Healthcare has been criticized for the tendency to bottom feed when it comes to risk reduction, meaning that we tend to rely on risk-reduction strategies low on the hierarchy. This doesn't mean that, as individuals, healthcare professionals don't care about risk or don't want things to turn out well. It simply means that we're more likely to select and implement interventions like "review policy" with individuals who make errors than to examine the underlying factors that allowed frontline workers to err. We spend a lot of energy attempting to teach front line clinicians how to save themselves.

So if we got out of the lifeboats and headed north on the risk-reduction hierarchy, how far could we go and what would the consequences be?

Health and healing are complex, and it's fair to say that we're sailing more than a few badly designed ships. 1 in 7 Americas lack healthcare insurance. Healthcare disparities are rampant. Patients are older, sicker, and rounder than they used to be. Our system does not incentivize prevention. A better design would avert many crises. But redesign of healthcare--something that appears to be emerging as a national priority--is outside the locus of control of individual clinicians, irrespective of how often or how nobly we face the consequences of the current bad design.

So how can front line clinicians prevent a poorly designed vessel from sinking? One answer is: embrace processes and procedures that make mistakes set in motion visible. Be able to identify emerging practice changes as the higher-level risk-reduction strategies they are. Get ready to cancel the launch!

A bar-code scan reveals a mismatch between ordered medications and a similarly packaged one in the patient’s drawer: you’ve cancelled a launch. A pre-procedure time-out reveals a site-of-surgery discrepancy: you’ve cancelled a launch. Reading back and verifying a telephone order (insulin 50, five-zero, units sub-cutaneously now) reveals the prescriber on the crackly line said one-five (15), not 50 units of insulin: you’ve cancelled a launch.

Cancelling a launch is not as good as preventing mistakes from occurring. But this approach trumps lifeboats and swimming lessons. Right now, healthcare is adopting, occasionally adapting, risk-reduction strategies from other industries, industries more reliable than ours.

The best risk-reduction strategies, in my opinion, are yet to come. As healthcare workers--bright, caring, and competent individuals—come to understand the principles that drive reliable performance, participate in developing highly-reliable processes, demand these be vigorously applied, and eventually come-of-age in an environment where reliability is the norm, it will no longer be necessary to report preventable adverse health events as aggregate data!

See you there!