Too few hospitals are learning safety lessons from near misses
In 2012, Chicago-based Presence Health began holding meetings called “report-outs” at its 12 hospitals to identify systemic problems that could hinder the delivery of high-quality care and possibly result in patient-safety mishaps. Such issues are identified by frontline staff and brought to the attention of leadership. During weeklong “breakthrough” events, staffers work rapidly to come up with solutions, and changes are implemented by the end of that week.
Systemic flaws that could or do lead to patient harm remain rampant in healthcare settings. But, unlike in aviation and other industries, those landmines are routinely ignored or put aside at many hospitals until they result in disastrous outcomes such as patient injuries or deaths. Root-cause analyses are seldom done for near misses.
That’s “a superficial and unsophisticated way to run a safety system,” said Dr. James Bagian, director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan.
Dodging a bullet should be looked at as an opportunity to fix a potential problem in advance, according to Bagian and a team of multidisciplinary safety experts in a National Patient Safety Foundation report released last week titled, RCA ² : Improving Root Cause Analyses and Actions to Prevent Harm.
The report urges hospitals and other healthcare providers to approach close calls with the same or greater rigor as they do when a major safety event occurs. No harm does not mean no foul, it said.
Though the term “culture of safety” has become commonplace in healthcare, making it a widespread reality has proved elusive, in part because establishing a safety culture involves hard, continuous work and can challenge the status quo.
One issue the NPSF report raises is that safety-event reporting systems are often designed to log incidents that have already happened, rather than looking at problems that were caught before an adverse event occurred.
Even getting hospital staff to use existing incident-reporting systems can be a challenge. Such reports captured only about 14% of the safety events experienced by discharged Medicare beneficiaries, and they were frequently not reported because of staff misperceptions about what constituted harm, a 2012 report from HHS’ Office of Inspector General found.
The incident-reporting concept “has not caught on,” said Dr. Ethan Fried, associate professor of medicine at the Hofstra North Shore-LIJ School of Medicine. He was part of the advisory board that developed the Near Miss Registry, an online anonymous reporting system run by the American College of Physicians’ Patient Safety Organization.
Only about 16 hospitals participate, and not all of them are actively reporting. The group estimates that 1 in every 8 near-miss events at participating hospitals are not reported.
Hospitals need to firmly embrace use of external registries or internal reporting systems, or else these efforts die, Fried said.
Sending memos and hosting town hall meetings about valuing opinions “are just words,” said Kathleen Long, director for breakthrough improvement at Presence Health. “It’s not just about encouraging people to tell the truth about what’s broken, but actually fixing it. When that happens, there’s a lot more confidence to come forward the next time something is broken.”
“Analysis alone doesn’t fix anything,” Bagian agreed. “If you don’t take the right action, the rest is a waste of time.”
Dr. Terry Fairbanks, director of MedStar Health’s National Center for Human Factors in Healthcare, said it’s time for healthcare providers to jettison the “bad apple fallacy,” in which the root cause ultimately points to human error. “That is just not an acceptable root cause,” he said.
If there is a systemic problem that leads to hospital staffers clicking on the wrong patient record because the electronic health record has a confusing display, for example, simply sending out a staff memo telling everyone to be more careful does not address the fundamental problem.
“Vigilance alone is not an effective solution,” Fairbanks said. “We need to change the design.”
That’s “a superficial and unsophisticated way to run a safety system.” Dr. James Bagian Director of the Center for Healthcare Engineering and Patient Safety University of Michigan