UH-OH Nearly 40% of the nurses and techs we surveyed say procedures sometimes commence without a pre-surgical hard stop.

Your surgical team is constantly striving to maintain a perfect safety record that patients expect and demand. It's a challenge they can't always meet, according to the findings that emerged from our patient safety survey of nearly 500 surgical facility leaders.

• Shortcuts. Nearly one-third of respondents say they see physicians and staff members taking shortcuts that could affect safety, either often (3%) or occasionally (27%), and only around one-fourth (24%) say they never see anyone taking shortcuts.
• Speaking up. While most respondents say staff members are comfortable speaking up when they see something that might compromise safety, many admit they sometimes hesitate.
• Time outs. Highly recommended and well-publicized measures intended to improve communication and safety — such as time outs — are still a long way from being universally accepted and adopted.
• Never events. Nearly half (44%) of respondents admit that their facilities have experienced a never event, such as wrong-site surgery.
• Arrogance. Most physicians, managers and nurses think they're better at their jobs than their co-workers think they are.
• Blame game. Most managers say they always emphasize learning over blame, but most nurses aren't sure that's true.

There's also some good news. More than 90% of respondents say they and their co-workers are always (73%) or usually (21%) actively looking for ways to improve patient safety. And those percentages are similar across the board for physicians, facility leaders, nurses and technicians.

With other issues, however, responses vary dramatically, depending on who's answering the question. For example, more than half of physicians (52%) and nearly two-thirds of facility leaders (64%) say everyone's ideas and suggestions are always encouraged, heard and valued. But only about one-third of nurses and technicians (32%) agree. "No one listens or has respect for other professionals' opinion or advice," one RN tells us. "We are to do what management says and not to think out of the box," insists another.

Of course, that could be a perception issue, points out Kris Sabo, RN, executive director of an Idaho surgery center. "Staff may not feel they are being heard if, for some reason, their idea is not implemented," she says.

Our survey suggests that you might want to increase the frequency or the volume when you assure staff that input is always welcome. On a similar note, the vast majority of respondents agree that staff members generally feel comfortable speaking up when they sense that something might compromise safety, but many admit they sometimes hesitate — especially in the presence of a surgeon they're intimidated by. "Physician egos and tempers can be a roadblock," says a pre-op and PACU supervisor. "There's a fear of retaliation in the form of a cold shoulder."

"Team members are much more comfortable speaking up with peers and nurses, and less so with physicians," says Anthony Polito, RN, BSN, a director of perioperative services from Buffalo, N.Y.

Maybe it should work the other way. Jeffrey Blank, DPM, an Illinois surgeon, says employees should pay a price for not raising their voices. "Our staff is trained to always speak up if something is not right," he says. "They all know they'll be reprimanded if they don't speak up."

QUESTIONABLE MARKS Nearly half of our respondents say their facilities have experienced wrong-site surgeries or other "never events."

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INSIDE THE NUMBERS
Patient Safety Survey

Does your facility always make patient safety its top priority? Do staff members feel empowered to speak up? Do some people take shortcuts that could compromise patient safety? We asked 469 caregivers at all levels for their opinions.

Staff members feel comfortable speaking up or asking questions when something doesn't seem right.
Always 44.6
Usually 44.4
Sometimes 8.4
Rarely 1.5
Never 0.9
Not sure 0.2

Everyone's ideas and suggestions are encouraged, heard and valued.
Always 48.5%
Usually 34.4%
Sometimes 12.6%
Rarely 3.7%
Never 0.9%

We allow enough time between procedures to prepare for the next one.
Always 32.3%
Usually 50%
Sometimes 11.5%
Rarely 5.4%
Never 0.9 %

New staff members are adequately oriented and trained.
Always 52.1%
Usually 35.2%
Sometimes 9.5%
Rarely 1.9%
Never 0.9%

We actively look for ways to improve patient safety.
Always 73.1%
Usually 20.7%
Sometimes 4.7%
Rarely 1.1%
Never 0.2%
Not sure 0.2%

When someone makes a mistake, we emphasize learning and de-emphasize blame.
Always 53.6%
Usually 34.8%
Sometimes 7.8%
Rarely 1.5%
Never 1.7%

We document near misses and use them as learning experiences.
Always 57.9%
Usually 27.5%
Sometimes 7.3%
Rarely 3.4%
Never 1.9%

We have fully engaged time outs.
Always 66.4%
Usually 27.2%
Sometimes 4.1%
Rarely 0.7%
Never 1.1%
Not sure 0.7%

Physicians encourage OR staff to speak up if something seems amiss.
Always 29.2%
Usually 29.2%
Sometimes 20.3%
Rarely 12.3%
Never 6.1%

Physicians treat team members as equals in the OR.
Always 20.4%
Usually 49.6%
Sometimes 20%
Rarely 5.7%
Never 3.3%

The OR team takes shortcuts that could affect safety.
Often 3.2%
Occasionally 26.5%
Rarely 44.2%
Never 23.9%

Has your facility ever experienced a "never event," such as a wrong surgery, wrong-site or wrong-patient surgery, retained object or patient burn?
Yes 43.9%
No 46.5%
Not sure 9.5%

TIME FOR A CHANGE? Many respondents say fully engaged time outs aren't necessarily the norm at their facilities.

Cutting corners?
The need for speed is another area that caregivers see differently. "The administration is more concerned with rapid turnover times than ensuring proper cleaning and preparation between cases," says a Florida nurse. "I frequently hear that we have a culture of 'hurry up, don't make the surgeon wait,'" acknowledges a facility manager.

Indeed, the numbers suggest that staff members feel pressure to cut corners with turnover. While nearly half of physicians (48%) say their facilities always allow enough time between procedures (and 42% of managers agree), nurses and techs say, no way. Only 19% agree that they always get the time they need.

And when something goes wrong? More than two-thirds of facility managers (68%) say they always emphasize learning over blame. But clearly there's a fine line between teaching and blaming. Almost 60% of nurses and techs say blame is sometimes the first response they experience.

Again, a matter of perception? "We try to make it a teachable moment but staff still view it as punitive," says one nurse. "I think no matter what, they feel like there is blame," says another.

Staff members tend to be defensive, says an infection control nurse manager from New York, "as if they're being targeted." Instead of embracing the opportunity to learn, "they become more involved in proving they weren't at fault," she says.

Born leaders?
"For a lot of doctors, quality and safety are someone else's job," says patient safety expert Kenneth Rothfield, MD MBA, CPE, CPPS, chief medical & quality officer at Saint Vincent's Healthcare in Jacksonville, Florida. "It all comes down to communication. We know it's the underlying thread in the overwhelming majority of patient safety events. Until we get that piece right, we're not going to fix the problem.

"To turn the tide with patient safety, we need physicians to get more training, and to become effective as leaders," he adds. "But the reality is that leadership usually isn't something you're born with. It's something you learn. Leadership is about sharing a vision and getting people to come along willingly, not about using authority to compel people to do things."

Are physicians being the patient safety leaders they should be? Slightly more than one-third (36%) say they and their fellow physicians always display strong leadership skills. But only 19% of facility managers agree, and only 7% of nurses and techs see physicians as consistent, dependable leaders.

Half of our physician respondents report that they always take time before procedures begin to encourage all team members to speak up if and when they have concerns. But their grades on that score are considerably lower from facility managers (32%) and from nurses and techs (23%).

"Most physicians display strong leadership skills," says a suburban Chicago facility manager. "But we have a few who would prefer to yell and belittle the staff." "Many get on the pity or negative train and encourage staff to do the same," adds a Dallas nurse.

No hard stop?
In what might be one of the more surprising revelations, more than one-fourth (26%) of physicians say they don't always conduct or demand fully engaged time outs before procedures, and almost 40% of nurses and techs say procedures sometimes commence without a pre-surgical hard stop.

"The doc tends to blow them off and make light of the time out in front of the patient," says an east Texas facility manager. Adds a Florida nurse: "It's done, but often half the staff aren't paying attention. Some surgeons see it as an annoyance rather than an essential procedure prior to beginning the surgery."

"Physician compliance with a complete and accurate time out remains an area for opportunity," says Mr. Polito, tactfully articulating the challenge.

It's anyone's guess as to how or whether any of the concerns readers express figure into the significant number of never events they've witnessed.

As noted, 44% of respondents say their facilities have had them. Considering that another 10% say they might have but they're not sure, fewer than half of respondents are left to say with some certainty that they haven't.

The events recounted by respondents cover a wide array, including:

• Wrong-site surgery. Spine surgery at the wrong level, wrong-site hernia repair, wrong tooth extraction, wrong cataract lens implant and wrong breast injection.
• Wrong-side blocks. Eye block and regional blocks.
• Retained objects. Tip of a drill guide and a lab sponge.
• Burns. Wrong prep leading to a corneal burn.

Several respondents say that new policies and procedures were put into place after those events occurred, and that they haven't happened since.

As clear as it is that patient safety isn't what we'd like it to be on a national level, our survey makes it equally clear that the vast majority of administrators, physicians and staff care deeply and work tirelessly to keep their patients safe. But the challenges are stubborn and varied, and our survey also reinforces the realization that a difficult journey lies ahead. It's often noted that the aviation industry found itself at a crossroads some years back, and responded by implementing a series of mechanical and interpersonal measures that have made air travel a model of safety.

Will it take something similar for patient safety to reach the same elite level — a system, perhaps, in which compensation becomes largely or wholly dependent on outcomes? Dr. Rothfield fears so. "We've had multiple things that look like wakeup calls for the industry," he says, "but we have a long way to go to provide the level of quality and safety that our patients deserve." OSM