Too few hos­pi­tals are learn­ing safety lessons from near misses

Modern Healthcare - - NEWS - By Sabriya Rice

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

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