Rethinking Patient Safety

Suzette Woodward

• Publisher: Productivity Press
• Year: 2017
• ISBN:
  9781351651066
• Edition: 1
• Topic: Medicina
• Subtopic: Sanità, amministrazione e assistenza pubblica

The vast majority of healthcare is provided safely and effectively. However, just like any high-risk industry, things can and do go wrong. There is a world of advice about how to keep people safe but this delivers little in terms of changed practice.

Written by a leading expert in the field with over two decades of experience, Rethinking Patient Safety provides readers with a critical reflection upon what it might take to narrow the implementation gap between the evidence base about patient safety and actual practice. This book provides important examples for the many professionals who work in patient safety but are struggling to narrow the gap and make a difference in their current situation.

It provides insights on practical actions that can be immediately implemented to improve the safety of patient care in healthcare and provides readers with a different way of thinking in terms of changing behavior and practices as well as processes and systems.

Suzette Woodward shares lessons from the science of implementation, campaigning and social movement methods and offers the reader the story of a discovery. Her team has explored an approach which could profoundly affect the safety culture in healthcare; a methodology to help people talk to each other and their patients and to listen through facilitated safety conversations. This is their story.

Chapter 1

Patient Safety

Medicine used to be simple, ineffective and relatively safe. It is now complex, effective and potentially dangerous.

Sir Cyril Chantler

1999

What Is Patient Safety?

The science of patient safety is relatively young. Early pioneers identified aspects of safety in the 1850s, but the science as we know it today grew substantially from around the mid-1990s. Patient safety is not a task or a set of technical interventions – it is a mindset, it is in everything we do. Feeling safe is one of the most important needs for our patients. Feeling safe and being safe. The act of keeping patients safe is about being constantly vigilant; noticing what happens every moment of every day, noticing when it goes right, noticing when it could go wrong and noticing when it does go wrong. With that knowledge, we then constantly adapt our behaviour and practice; constantly refine our performance or our way of working so that it gets safer and safer and safer. Patient safety is about making small incremental improvements in any process that add up to a significant improvement when they are all added together. It is not about a single solution, a single person or a one-size-fits-all approach.

In my view, there is a fundamental difference between patient safety and quality. Patient safety is not a subset of quality – it is a unique science, a specialist field of healthcare that applies safety science methods towards the goal of achieving a safer system. Safety is not the same as quality, nor is it the same as effectiveness or reliability. Healthcare can be of high quality but unsafe; it can be effective and reliable but unsafe. It can also be safe but of poor quality, ineffective or unreliable. There are unique aspects to patient safety that are not generally thought of as about quality improvement. These includes aspects such as preventative risk analysis and designing equipment and systems to make them easy and intuitive to use and as error-proof as possible, as well as using investigative methodologies to truly understand why things go wrong.

The focus seems to have shifted away from understanding human error and risk, two vital components of patient safety, to a focus on quality and quality improvement. This is diverting attention from the unique and specific aspects of patient safety that require addressing; it is also diverting policy, research and resources away from safety and safety improvement. The quest for safety is not in opposition to pursuing other aspects of quality, effectiveness or experience, for example, but there is a need for a distinct and separate focus on safety rather than it being simply a component of quality. Safety is an essential building block for achieving high performance in all other areas. We dilute its importance by focusing on quality instead.

Despite all the hard or technical barriers we can put in place, we are human and we are frequently reminded of our human fallibility when we make mistakes or errors, slips or lapses. At the very heart of safety is keeping people safer; people are usually the final barrier between a safe act and an unsafe act. In most industries, and in particular healthcare, people are dependent on other people. How those people get on, interact, communicate and work together can make or break safety. The problem is we have not focused enough on helping these people be safer and creating relationships that enhance safety; we have focused too much on the technical and not enough on the non-technical aspects of patient safety.

What does safe look like? First, we will never be safe. As Professor James Reason says in the foreword to Close Calls (Macrae 2014b), there are not enough trees in the rainforest to write a set of procedures that will guarantee freedom from harm. Healthcare will always carry risks; human beings are fallible. However, harm to patients should not be viewed as an acceptable part of modern healthcare. Unsafe care results in far too many individual tragedies every year, with both patients and those who provide their care suffering as a consequence. If we are to save more lives and significantly reduce avoidable patient harm, there is a need for a change in perspective. It’ s needed because it is also personal. We and our families and friends could be the next ones affected. It’ s needed because knowingly offering a patient unsafe care is morally and ethically wrong. Healthcare is a safety-critical industry and patient safety must be our core business.

Pioneers

There are undoubtedly many unsung and unpublished individuals who have noticed aspects of poor patient safety and attempted to change behaviour and practice in order to minimise harm to patients. For all those who have not been recognised, there have been a few in our history who have been noticed and these include the early pioneers of patient safety such as Florence Nightingale, Ignaz Semmelweis, Ernst Codman and Herbert William Heinrich.

Nightingale is clearly known for being at the forefront of nursing and nurse training, but she is also one of the earliest patient safety thinkers and statisticians. Measurement experts today would love the fact that Florence Nightingale regarded statistics as the foundation for change and the most important science in the whole world. In the mid-1850s, she noticed that many of the soldiers were dying in ways that she intuitively thought were avoidable. She plotted all of the reasons why soldiers died in the army in the Crimean War from April 1854 to March 1855 and found that most of the soldiers’ illnesses were caused by what she describes as ‘ defects in the system’ . She deduced that perhaps at least one in seven of the patients (around 14%) died from preventable diseases rather than their battle wounds. As a result of this work, she made huge improvements to the way the soldiers were being cared for. These were not isolated interventions but fundamental aspects of care: good nutrition, warm clothing and good ventilation, and most importantly, cleanliness and hand hygiene (Huxley 1975).

Ignaz Semmelweis was a Hungarian physician who, also in the 1850s, around the same time as Nightingale, wanted to understand why some of his patients died after childbirth. The detailed story of Semmelweis and his relentless pursuit of addressing maternal deaths is a fascinating one and this summary really only skims the surface of his story. Not only are the lessons from this story relevant to patient safety but they are also pertinent for anyone trying to convince others to change and trying to be heard.

Semmelweis worked in one of the first obstetric clinics in Vienna. These institutions had been set up all over Europe to provide free care, which made them attractive to ‘ underprivileged’ women, including prostitutes. In return for the free services, the women would be subjects for the training of doctors and midwives. In his first publication, Semmelweis (1857) describes the tale of two maternity clinics at the Viennese hospital that he worked at. The first clinic had an average death rate from an infection called puerperal fever of around 10%. The second clinic’ s rate was lower, averaging less than 4%. Interestingly, this fact was known outside the hospital and the women begged to be admitted to the second clinic. Semmelweis described how desperate women were begging on their knees not to be admitted to the first clinic. In fact, some women even preferred to give birth in the streets. Semmelweis was puzzled and deeply troubled by the fact that puerperal fever was rare among women giving street births and that the first clinic had a much higher mortality rate. The two clinics used almost the same techniques, and Semmelweis started a meticulous process of eliminating all possible differences between them. He excluded a variety of potential causes; the only major difference was the individuals who worked there. The first clinic was the teaching service for medical students, while the second clinic had been selected in 1841 for the instruction of midwives only.

In 1847, one of his friends died after being accidently stabbed by a student’ s scalpel while performing a post-mortem. The friend died of the same puerperal fever that the women were dying from. He proposed that the cause was, in fact, the doctors and medical students, who were routinely moving from the task of dissecting corpses to examining new mothers without first washing their hands. They transferred infections from the corpses to the mothers, causing their deaths as a consequence. The midwives were not engaged in autopsies. He issued a policy of washing hands between autopsy work and the examination of patients. The result was that the mortality rate in the first clinic dropped by 90%. When the doctors, medical students and midwives washed their hands, the number of deaths from infections went down.

What happened next is as interesting as his findings. Despite what appears to be compelling evidence and results that reduced mortality to below 1% from that of between 10% and 35%, his observations conflicted with the established views at the time. His ideas were rejected. Semmelweis not only failed to convince his colleagues enough to change their practice, he angered and offended them. In fact, there is today a phrase that has been used to describe his challenge, which is named after him: the Semmelweis reflex . This is used as a metaphor for human behaviour that is characterised by a reflex-like rejection of new knowledge because it contradicts entrenched norms and beliefs (Leary 1991). As he grew more frustrated and angry at what he felt was a disregard for people’ s lives, he grew more and more erratic and he even at one point called his colleagues murderers. Semmelweis was truly misunderstood and undervalued for his work. He only really earned widespread acceptance years after his death at the age of 47. He died of septicaemia only 14 days after being committed to a mental health institution.

Ernest Codman was a pioneering Boston surgeon who graduated from Harvard Medical School in 1895 and worked at Massachusetts General Hospital. He was interested in why patients died, and kept track of every patient outcome (Donabedian 1989, Berwick 1989). He followed up every patient for at least a year to observe long-term outcomes and to identify ‘ clinical misadventures’ . He believed that all his information should be made public so that patients could choose which doctors and hospitals they were treated at. He also was not listened to by his colleagues and eventually had to establish his own hospital to implement his improvement methods. Not only did he publish the deaths, he also published his opinions on whether they could have been prevented. Of 337 patients discharged between 1911 and 1916, Codman recorded and published 123 errors. He tried to understand what the possible causes of these errors were and set up group conversations about these outcomes through the use of morbidity and mortality meetings. This is an early example of the use of conversations and storytelling in patient safety.

Herbert William Heinrich was born in 1886. He was an American industrial safety pioneer who created the domino model, which was published in 1931. Heinrich compared the sequence of an incident to a row of dominos, and that if one domino falls, it automatically knocks down its neighbour and so on until they all fall (and the injury or incident occurs) (Leveson 2012). Heinrich’ s sequence started with the environment, then the person and then the unsafe act, leading to accident and injury. Heinrich’ s Law is named after him: in a workplace, for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injuries. Heinrich expressed this idea in a safety pyramid in 1959 (Heinrich 1959, Roos et al. 1980). He believed that many accidents share common causes and that addressing an accident that caused no injuries could prevent an accident that did. He suggested that 95% of all workplace accidents are caused by unsafe acts by humans, and because of that he encouraged employers to put in controls in the workplace that might prevent these unsafe acts from happening.

Over One Hundred Years Later

Literature searches relating to patient safety reveal very little until we reach the 1980s. Anaesthesiologists were the first to truly embrace the concepts of patient safety, and during the 1980s became the leading specialty to address the safety of patient care. This work significantly reduced the risks associated with anaesthesia, which even today is one of the safer aspects of patient care as a result. Anaesthesiologists held symposiums on deaths and injuries as well as forming the US group the Anesthesia Patient Safety Foundation (APSF) in 1984. This, interestingly, may well be the first use of the term patient safety. In 1989 in Australia, the Australian Patient Safety Foundation was founded in order to capture anaesthetic events and errors.

Forerunners of this period included Jens Rasmussen, James Reason, Lucian Leape, Charles Vincent and Don Berwick. These were individuals from very different backgrounds but who came to similar conclusions.

Jens Rasmussen was a systems safety and human factors professor in Denmark (Rasmussen et al. 1987). He was followed by others, including James Reason, who had worked predominantly in high-risk industries such as the nuclear industry and aviation and had written a book all about the different types of human error. Reason (1990) described why mistakes and errors happened using the now famous ‘ swiss-cheese’ model of error. Over the subsequent 25 years, Reason has helped rewrite critical assumptions about why things go wrong and he has constantly challenged the thinking on human error and patient safety. He is an undisputed master and has a unique way of helping us understand what can and should be done.

It was really only in the 1990s that we started to understand the nature and scale of avoidable harm. We saw the rise of clinical risk management and the use of methods normally used by aviation and mechanical engineering applied to anaesthesiology.

Reason taught us that human error is the inadvertent action of doing something wrong; something that was not how it should have been done, a slip, a lapse, a mistake. He reminded us that we all make mistakes all of the time, like picking up the wrong keys, forgetting your ID, miscalculating a medication dose, missing a turn-off from the motorway, picking up strawberry yoghurt instead of raspberry or calling our children by the wrong names. Most of these errors that we make every day have generally minimal consequences. In healthcare, however, we can make similar types of errors with the potential for dire consequences.

Lucian Leape (1994) wrote about error in medicine, Charles Vincent (1995) wrote one of the first books on clinical risk management and Don Berwick is a paediatrician who studied at Harvard Medical School in Boston. In 1983, Berwick became one of the first people to hold a role in quality measurement in addition to his clinical duties. He learnt from other high-risk industries, including aviation and manufacturing. He co-founded the Institute for Healthcare Improvement in 1989. Berwick has spoken and published widely on the subjects of quality improvement and patient safety, many of which are referenced throughout this book. All of us in safety have trailed behind these thinkers and we owe them a great debt of gratitude.

Building on the 1980s, our knowledge started to grow in the mid-1990s. For example, in...