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10 January 2019
By Brigitta U Mueller MD, MHCM, CPHQ, CPPS, FAAP, Vice President for Medical Affairs and Chief Safety Officer, Johns Hopkins All Children’s Hospital, Professor of Pediatrics, Johns Hopkins University School of Medicine, Maryland, U.S.
The journey to high reliability, safe and high-quality care is ongoing in hospitals around the world. The goal is to eliminate all preventable harm that occurs while patients are under our care. Progress has been made but too many children and adults are still being harmed in our facilities.
As has been known for almost two decades, healthcare is not as safe as it should and could be. Although patient safety is only one of the six domains of quality of care defined by the Institute of Medicine (IOM [now the National Academy of Medicine]), it is undoubtedly one of the most important.
Since the publication of the 1999 IOM report, “To Err Is Human,” there have been dramatic increases in research, standards, collaborative efforts, education, and measures focused on patient safety. However, despite increased awareness, harm to patients is still common and has not shown a significant decline. At least one out of 10 hospitalised patients is being hurt by us and at least half of these events are preventable. In paediatrics it may be even worse: errors still affect as many as one third of all hospitalised children and an unknown number of children in ambulatory settings.
Seven principles are being used to diminish harm and achieve high reliability in the daily performance of any organisation, including hospitals. They include:
Preoccupation with failure: Real time awareness of failures, achieved by daily monitoring of processes, reporting of near misses, and an enhanced sensitivity to processes that could potentially fail before they actually do.
Reluctance to simplify: The first, obvious explanation for a failure may not be the right one, and it is rarely a single issue that leads to the error.
Sensitivity to operations: Leaders and staff are constantly aware of how processes and systems affect the organisation. Any process that does not work is highlighted and modified in real time. Transparency is a valuable tool to increase sensitivity to operations.
Commitment to resilience: Failures and especially near-miss situations are considered learning opportunities. High reliability organisations are constantly learning, improving, and testing new ways of operating.
Deference to expertise: This includes taking advantage of the different levels and areas of expertise that team members contribute, and the recognition that the most senior person is often not the most knowledgeable.
Deliberate leadership practices and organisational commitment are needed to establish a culture of safety and foster the journey to high reliability. Although no single intervention will suffice, the importance of leadership presence and support has been emphasised by many organisations, including the Joint Commission. The commitment to zero harm has to come from the top leaders in an organisation and permeate through both clinical and non-clinical areas. Involvement of the Board of Governors is crucial but requires a well-informed Board familiar enough with the issues of hospital-acquired conditions (HACs) to be able to set certain expectations. Management of the hospital, from the CEO to frontline staff, have to be trained to recognise their role in eliminating harm and commit to a culture of constant vigilance and willingness to improve. It is important to realise that zero harm does not mean zero errors and that it is instead essential to create a culture that supports the principles of a highly reliable organisation as described above.
Organisations can introduce Executive Safety Rounds to increase awareness of safety concerns among executives. This provides an opportunity for frontline staff to share safety concerns that affect either the delivery of care or their personal safety, and for executives, if possible, to provide solutions. The Executive Safety Rounding team at our hospital is comprised of an executive leader (such as the Chief Patient Safety Officer), other executives or senior clinical or non-clinical leaders, a member from the Patient Safety and Quality team, and ad hoc members (residents, Patient Family Advisory Committee or Hospital Board members, etc). The one hour rounds can either occur on different days of the week and at different times, including evenings and early mornings, or on a fixed schedule. Ideally, it would include both clinical and non-clinical areas, both within the hospital as well as in outpatient settings.
Another way to raise awareness about safety issues is a daily, organisation-wide, short (15 minutes) safety call or meeting where different areas report out about any safety issues that occurred during the u last 24 hours or any concerns regarding the next 24 hours. This should include clinical and non-clinical areas, such as facilities, information services and security. Issues discussed can range from census numbers to staff shortages or equipment problems, but could also include weather alerts, reminders about participation in organisation-wide initiatives, such as the annual influenza immunisation campaign and many more.
Peter Drucker, a leader in management principles, supposedly said, “If you can’t measure it, you can’t improve it”. To know whether we make progress in our culture of safety, and even more importantly, where we have opportunities for improvement, it is helpful to deploy a standardised safety culture survey at least every 18-24 months. An example of a freely available tool is the survey created by the Agency for Healthcare Research and Quality (https://www.ahrq.gov/sops/quality-patient-safety/patientsafetyculture/hospital/index.html).
Another important step is the creation of a dashboard with established benchmarks that are updated regularly. This dashboard needs to be prominently displayed and the results discussed at staff as well as Board meetings. A list of items to be addressed can also be created locally. Comprehensive Unit-based Safety Programs (CUSP) teams are comprised of multidisciplinary frontline staff who concentrate on solving safety concerns that occur at the local level. An executive member of the team can help overcome any logistical or administrative hurdles. This concept has been successfully introduced around the world.
Children’s hospitals have some unique challenges due to the wide range of weights and ages of their patients. Paediatric patients can be harmed in different ways. Medication errors are the most common adverse event in children, in part due to the necessary weight and age adjustments for dosing. Errors can happen at any time during the process of prescribing or administration, and they can occur both in the hospital and the ambulatory setting, including in the child’s home. An additional source of error can be introduced when substitute medications need to be used due to drug shortages, a relatively common problem both in industrialised and developing countries. Diagnostic errors or a delay in diagnosis may be caused by a failure to order indicated tests, the use of inappropriate or outmoded tests or therapy, or a failure to act on results of monitoring or testing, or they may occur because of the age of the child and the inability of the young child to verbalise complaints. Therapeutic errors can, like in adults, occur due to the failure to adhere to guidelines, staff fatigue, or interruptions during critical actions.
However, what has received the most attention are infectious complications, especially surgical site infections, catheter-associated blood stream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). Many of them have successfully been targeted with standardisation of care. Interventions such as strict adherence to hand hygiene, asepsis during catheter insertion, adherence to a maintenance bundle and the use of an appropriate dressing, have drastically decreased the incidence of CLABSIs and CAUTIs. Networks, such as Solutions for Patient Safety (https://www.solutionsforpatientsafety.org/) provide an opportunity to learn from peers and to share experiences and best practices. Some organisations have been able to maintain zero infections for months and even years, an achievement that previously was thought to be impossible.
As we have learned over the years, zero harm can only be achieved and maintained with constant vigilance. New staff has to be trained and current staff practices must be monitored on a regular basis, since deviations in practice (for example, short-cuts) tend to creep into routine tasks. For example, when we asked each of our nurses to demonstrate their techniques of caring for a central venous line we realised that, although everyone had been properly trained, a wide variability in practice had become established, possibly increasing the risk for infections. A periodic retraining in proper techniques may help avoid such situations.
Finally, we cannot underestimate the value of including families in our patient safety efforts. For example, if a family helps make sure that all healthcare providers and other staff (registration, food services, etc.) as well as visitors adhere to good hand hygiene procedures, they help us protect our patients and keep us all accountable.We still have a long way to go, but we have developed many different tools to help us achieve our goal of zero harm.
References available on request.