Speaking up for patient safety

Hospitalists can help create a blame-free atmosphere of openness when it comes to discussing errors in patient care.

Despite years of studies and related discussions about medical errors, the willingness of hospital clinicians to raise patient safety concerns remains frustratingly limited, according to data and patient safety experts.

Photo by Thinkstock
Photo by Thinkstock.

Consider the findings from a safety culture survey published by the Agency for Healthcare Research and Quality (AHRQ) in 2012, involving 1,128 hospitals and nearly 570,000 hospital staffers:

  • —53% aren't comfortable questioning the decisions or actions of those with more authority,
  • —50% feel like their mistakes are held against them, and
  • —46% believe that when an event is reported, it's the person, not the problem that gets written up.

Finally, just 55% of staffers had reported a potential safety issue—defined as some area needing improvement—during the prior 12 months. Experts say that percentage is much too low.

“When safety experts see that number, it makes them feel nauseated,” said Thomas Gallagher, MD, FACP, a patient safety researcher, who also directs the hospital medicine program at the University of Washington in Seattle. “Because they know that adverse events and errors happen regularly. Health care workers are seeing them all of the time.”

Dr. Gallagher and other patient safety advocates see numerous hurdles to better reporting—everything from discomfort to poor guidance about which concerns should be documented to a belief that no changes will result.

Various safety tools have been developed in recent years, including communication techniques like SBAR (Situation-Background-Assessment-Recommendation) and the initiative TeamSTEPPS (developed by AHRQ and the Department of Defense).

But these tools don't accomplish much unless a culture of psychological safety has been created by hospital administration or front-line leaders such as hospitalists, experts said.

System improvements

The AHRQ survey showed a lack of progress in building this culture. Fewer than half of staffers—44%—described their facility as non-punitive in its response to adverse events reporting, a rate that remained unchanged from the 2008 report.

“In fact, there should be rewards for people who do report—they should be encouraged,” said James Battles, AHRQ's manager for patient safety culture efforts in Rockville, Md. Reports should include the full range of problems that can develop, from clear-cut errors to near misses to worrisome patterns, he said, “because it's what you don't know that's really going to hurt the organization.”

To encourage more clinicians to step forward, hospital and physician leaders must be explicit about what type of safety concerns they want disclosed, said Tejal Gandhi, MD, MPH, an internist in Boston and president of the National Patient Safety Foundation, which commemorated Patient Safety Awareness Week this month (March 2-8).

Good hospitalist leaders always have a positive, open attitude when talking about the reporting of safety concerns, noted Michael Leonard, MD, an adjunct professor of medicine at Duke University School of Medicine in Durham, N.C., and co-founder of the firm Safe & Reliable Healthcare. “They continuously invite the team members into the conversation,” he said.

When someone reports a problem, follow through to update the staffer on what happened in response, even if you're just explaining why no immediate action was taken, recommended Dr. Gandhi, who previously was the chief quality and safety officer at Partners HealthCare in Boston.

“People are really happy just to know that somebody looked at it,” she said. “Because if they think it's going into a black hole, and no one is paying any attention to it, then they certainly are not going to report.”

Kedar Mate, MD, ACP Member, an academic hospitalist and a vice president at the Institute for Healthcare Improvement (IHI) in Cambridge, Mass., said he's relayed as many as a dozen safety concerns over the course of his years as an attending physician, but he's “virtually never” gotten any feedback about what happened with that information.

Along with providing feedback, hospital leaders should spell out why they're collecting certain types of information, other than that some agency requires it. “If you can demonstrate that we're collecting the information for the sake of improving your systems, I think there will be an increase in the willingness of people to report,” said Frank Federico, RPh, one of IHI's directors and patient safety experts.

Doctors and nurses also shouldn't be burdened by multiple pages or boxes on a computer screen to raise a potential safety issue, both IHI leaders stressed. Hospitals should strive, Dr. Mate said, to make adverse event reporting as easy as billing. Mr. Federico described one electronic health record that requires roughly 7 screen changes to document a patient care concern.

Walking the talk

To foster more frank discussions, some hospitals organize periodic walkarounds with a few key executives visiting with clinicians on specific units, Dr. Gandhi said. Among the questions they might ask: What's working well and what's not? Who was the last patient harmed and what was learned?

Another strategy is to focus some morbidity and mortality (M&M) conferences on patient safety. Instead of selecting a challenging diagnostic case, Dr. Gandhi suggested that hospitalists highlight a scenario in which the patient's care didn't go well. Don't place blame on any individuals, but dissect where the system broke down and how it might be fixed. Be sure to designate someone to follow up on potential solutions, she said.

Ideally, the details of those M&M discussions should also be fed into the organization's safety reporting system to enrich that database, Dr. Gallagher said.

M&M conferences aren't the only places where one has to think carefully about blame. Physicians tend to think the failure to report safety issues is due to staffers' fear of the health system's leaders or the legal environment, Dr. Gallagher said.

“What they don't realize is that a huge portion of that blame culture originates from within. It originates from the attitudes and behaviors of individual clinicians,” he said. “For example, when physicians choose to report adverse events only when they're wanting to get someone in trouble, that's an important contributor to the shame-and-blame culture that's getting in the way of learning.”

Dr. Leonard, who helped design the SBAR to bridge differing communication styles between doctors and nurses, has observed similar issues. It's rare for him to visit a hospital where the clinicians haven't heard about the SBAR approach, he said. But then he asks if they use it.

“The usual answer is, the nurses will say, ‘We use it with the doctors we like. And we use it with them, because they don't give us a hard time.’ So they use it with the people they feel safe with,” Dr. Leonard said.

For their patients' safety, hospitalists should try to be one of the doctors in that group. If, for example, a physician feels like there was a negative interaction or a pattern of bad communication with a particular nurse, sit down one-on-one and calmly discuss any communication gaps, Dr. Leonard recommended.

“Never be a jerk to anybody, because that's the most dangerous behavior in a hospital,” he said. “It's only going to increase the threshold regarding whether they'll speak up the next time.”