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Let's Team Up to Prevent Patient Harm
Our exploration of surgical safety kicks off with a look at the persistent problem of medical care gone wrong.
Daniel Cook
Publish Date: January 9, 2017   |  Tags:   Patient Safety
medical errors IN GOOD HANDS? Avoidable medical errors kill hundreds of thousands each year.

This is the first installment of our year-long series dedicated to addressing the underlying causes of medical errors, and discussing what can be done to promote patient safety in surgical facilities across the country. We pledge to provide you with insights and advice from leading safety experts. You can hold up your end of the bargain by inspiring your clinical team to do better, because patients don't deserve to leave your facility in worse shape than when they arrived. Let's start the conversation with a straightforward question: Why do surgical errors keep happening? The answer, it seems, is a bit complicated.

Culture clash
A pair of recent studies grabbed national headlines by claiming medical care gone wrong kills either 250,000 or 450,000 people each year, depending on which researchers you believe, making it the third leading cause of death — behind only cancer and heart disease — in the United States. Some questioned the evidence and debated which estimate is more accurate. What difference does it make? There's only one number that matters.

"It should be zero," says Sue McWilliams, RN, MSN, of the Northern Arizona School of Nursing in Flagstaff and an advisor to CaimpaignZero, an advocacy group dedicated to preventing the medical errors that cause patient harm.

Ms. McWilliams spent some time as a surgical nurse during her 30-year career in health care. Nine months, to be exact. It was the stress of the OR that drove her to follow her passion in more relaxed clinical settings.

Does the pressure-cooker environment of the OR put undue strain on the surgical team, forcing them to keep patients moving through the facility instead of focusing on the one who's on the table? Does the lashing out of stressed-out surgeons distract cowering nurses and techs from protecting patients?

Yes, perhaps a surgical team who's constantly pushed to increase case volumes or meet certain efficiency benchmarks can't focus fully on doing their jobs properly, says Ms. McWilliams. She suggests you explore ways to ease up on their daily workloads. Do you need to add more nurses? Would scheduling cases based on the realistic capabilities of your staff make a difference?

"We've made great strides in changing the culture of surgery, but that needs to be continually brought up as an important factor in the prevention of surgical errors," says Ms. McWilliams. "That starts with administrators saying, 'We want to provide the safest possible care for our patients under the highest-quality working conditions for our staff.'"

You can implement checklists and perform time outs, but errors will continue to occur if members of the surgical team aren't confident enough to speak up and don't have the respect of their peers when they walk into the OR, says Ms. McWilliams. "Until we recognize the importance of workplace culture," she says, "we're going to keep ignoring the elephant in the room."

If it could (almost) happen to him
Bill Berry, MD, MPH, MPA, FACS, surgical consultant to the Risk Management Foundation of the Harvard Medical Institutions, recalls a time when human error almost put him in harm's way. He was in the office of his orthopedic surgeon the day before surgery to repair a bone in his left foot. After he signed the consent form, his wife tugged on his sleeve and said, "You just consented for surgery on your right foot."

A human unsupported by automated checks filled out an inaccurate consent form that Dr. Berry signed without a second thought. How many times do you think that scene plays out in surgeons' clinics across the country? "I was really nervous — and I'm a surgeon and patient safety expert," says Dr. Berry. "If anybody could have armed themselves against an error in care, it should have been me."

"There are problems embedded in the systems of surgical care, not in the people who are performing it."

— Bill Berry, MD, MPH, MPA, FACS

But he didn't. If his wife hadn't intervened, the inaccurate consent form might have made it into the OR the next day. "And the double checks that every surgical team is asked to perform wouldn't have caught the mistake," points out Dr. Berry. "A time out would have reinforced the wrong site. The potential for harm was generated in the clinic."

Dr. Berry spent 10 years of his career reviewing malpractice cases, and recognized a common cause of medical errors. "There are problems embedded in the systems of surgical care, not in the people who are performing it," he says. "The processes surgical professionals follow often set them up for failure. There are many right ways of doing things, but we don't agree on which one we're going to use."

Every surgeon has his own way of doing things, so every nurse needs to know each doctor's preferred methods. "That's impossible, so they make way more mistakes than they need to," says Dr. Berry.

It's true that surgical professionals aren't the ones at risk of being physically harmed when errors occur, but Dr. Berry is quick to point out that the mental scars can sometimes cut just as deeply. "Every caregiver who sees a patient get injured is hurt inside," he says. "There's tremendous psychological pain that comes with making significant errors that result in patient harm."

Ashley Childers, PhD, a research assistant professor in the department of industrial engineering at Clemson University, is a systems engineer who's working to retrain the way surgical professionals view the processes of surgery. "They think about their patients, tasks and duties, but not necessarily about the entire continuum of care," says Dr. Childers. "That's not a bad thing. It's just the way they've been trained."

Her outsider's message hasn't always been received positively by surgical professionals who worry about treating people like widgets. "That's not what I want to do, but you need to find and reduce the variability in the systems surgical teams use," says Dr. Childers.

checklists MAKING A MARK Checklists are useful safety tools only if they're used reliably and meaningfully.

To err is not an excuse
Surgical professionals need to be mindful of safety procedures and the principles of highly reliable delivery of care, says Lorri Gibbons, RN, MS, vice president of quality and safety for the South Carolina Hospital Association. "When you become more reliable, you decrease the risks of errors and the harm they can cause," she adds. In other words, you don't necessarily stop mistakes from happening, but you prevent the potentially harmful ramifications from reaching the patient.

Leaders at surgical facilities need to look at how theirs can become the safest possible entities. "You're not going to do it all at once, and just because you have a high rate of safety in one area doesn't mean you can stop trying to improve," says Ms. Gibbons. "You have to build a foundation based on the principles of becoming highly reliable, and grow your safety program incrementally. Staff will begin to think about surgical safety differently before their behaviors change. When that happens, you'll see drastic improvements occur."

Dr. Berry says improving the safety of surgical care is more marathon than sprint. "We need to recognize that it's going to take a while to get to where we want to go," he says.

In the short term, say over the next 12 months, he suggests you focus on making the time around the use of checklists and time outs as meaningful and as reliable as possible. "When those points in care come, if we're being honest, not everyone in the room is paying attention, and not everyone gets a chance to say they're ready for the case to begin," says Dr. Berry. "Addressing that aspect of care would improve the safety performance of many, many facilities."

Additionally, create an internal system to fix problems that are identified during the course of a workday. "I'm a big fan of short debriefs at the end of procedures to make sure oversights are addressed and solved," says Dr. Berry.

Errors will continue to occur, because we're only human is not the mindset surgical leaders should have, says Ms. Gibbons. "Zero patient harm is obtainable," she adds. "We're a special group of professionals working in a high-impact system. There needs to be more scrutiny on the processes of care, so we can mitigate anything that's a potential risk." OSM