Creating the culture of safety - President's Message

AORN Journal,  Feb, 2003  by Donna S. Watson

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In the past, when a medical error occurred that resulted in a patient being harmed, it frequently was resolved in a manner that placed blame on an individual. When an error occurred, the physician, nurse, or pharmacist was assumed to be careless. The consequences of the error often resulted in an individual being dismissed, thus seeming to resolve the problem of future occurrence.

Medical errors are complex, however, and they may not be the result of individual practitioners' practices or even a single factor. Many medical errors are a consequence of faulty systems that unintentionally allow potential errors to occur repeatedly and go unnoticed until a patient is harmed. When a single factor is examined in isolation, it rarely indicates the faults in a system. When the same factor is examined as it relates to implications and potential outcomes of the system of which it is a critical component, problems with a poorly designed system become apparent and the potential for patient harm is recognized.

The complexities of the health care system frequently are compared to those of the aviation industry. Both industries experience errors that often are caused by the failure of the system and that result in poor outcomes. As health care providers, we should approach our work environment from the standpoint of safety. We need to look for opportunities to identify and correct a single factor that ultimately may result in harm to a patient.

THE POTENTIAL FOR ERROR

Practicing in the perioperative environment places every perioperative nurse at an increased risk to be involved in a potential patient error based on the environment alone. Perioperative practitioners need to have a specialized skill set to be effective patient managers in ultra complex health care settings. This environment consists of sophisticated and rapidly changing technology, multiple layers of interdisciplinary interactions, complex communication flow, and physically and mentally demanding challenges. In addition, at any moment a decision made by any member of the surgical team can result in a life or death outcome.

Since 1996 in the United States alone, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has received reports of 150 occurrences of wrong site surgeries, including surgeries on the wrong arm, leg, eye, kidney, patient, and body part. (1) In its report To Err Is Human: Building a Safer Health System, the Institute of Medicine reports that more than one million occurrences of preventable medical mishaps occur annually, resulting in as many as 100,000 deaths. (2) Medication errors lead the list with an estimated 770,000 adverse drug events that result in death or injury annually. (3) At a recent conference I attended, one unit in one facility reported 75 near misses in a single month after implementation of a bar code labeling system. (4)

Increased media attention on medical errors has resulted in a local and national culture shift on the issue of patient safety. In 2001, JCAHO implemented new standards that require health care organizations to develop ongoing patient safety programs. (5) As a result, perioperative services are participating in redesigning delivery of patient care to prevent and reduce errors. Patients enter the health care system to receive nursing care and medical management for acute or chronic conditions; no patient enters the system thinking that he or she may a life-threatening injury resulting from a medical error.

Many nursing and medical professionals are aware of the case of Betsy Lehman, a 39-year-old medical reporter for the Boston Globe, who died from a chemotherapy overdose at the Dana-Faber Cancer Institute of Boston. (6) This error resulted in the dismissal of the resident physician and senior attending physician. Additionally, at least 15 nurses received reprimands from the Massachusetts Board of Registration in Nursing. Was there a culture of safety for reporting at the Dana-Faber Institute that could have prevented this tragic error?

It is critical to have a safe culture for reporting, even if direct patient harm does not occur. The potential for error exists, so it is likely to occur again and may result in actual patient harm. When looking at incidents that could have resulted in patient harm (ie, near misses) ask yourself if this could have occurred to any nurse, physician, or surgical technologist in a similar situation. If the answer is yes, the incident likely is the result of a systems error, and the chances of it reoccurring are substantial.

Creating a safe culture for reporting and removing threats is a challenge for every health care facility. The health care industry needs to move from a punitive system that places blame on the individual to a safe reporting culture that emphasizes the impact of the system and how the system may or did fail to help providers deliver appropriate outcomes.

WHEN AN ERROR OCCURS

Many health care facilities are implementing policies and protocols related to full disclosure about significant patient errors to the patient and his or her family members. One facility says that a full disclosure policy has reduced claim payments from $1.5 million to $180,000 annually. (7) At this facility, when a significant patient error occurs that results in a patient injury, the patient and family members are informed, institutional accountability is acknowledged, and options and remedies are implemented with input from the patient and his or her family members. Implementation of this strategy has resulted in direct communication with the patient and family members in a manner that is timely, respectful, and honest.