First do no harm! That quote from Hippocrates, the father of modern medicine, is familiar to anyone working in health care. Yet a 1999 Institute of Medicine Report, “To Err is Human: Building a Safer Health System,” found that as many as 98,000 people a year died from medical errors that occurred in hospitals.
“We always thought that we had the best health care in the world. To find that we were killing almost 100,000 people a year through medication errors, misdiagnoses, health care-acquired infections, and other errors stunned the health care community,” said Nancy Curdy, MSN, RN, ANP-C, CCNS, CPHQ, director of patient safety, reliability and infection prevention at DeKalb Medical. “It made everyone sit up and take notice. No one goes into health care to hurt people. We’re in the business of helping people stay well.”
That report and its recommendations launched a national patient safety movement. Hospitals have been on a journey to provide for patient safety ever since. Through science, better standards and measurements, ingenuity and perseverance, they are creating safer health care environments for everyone.
“We are starting to move the needle in the right direction,” said Curdy. “Patients are safer today. Nothing improves a system like everyone being on heightened alert.”
Here’s a sampling of what heightened alert looks like in a few Atlanta hospitals.
Nancy Curdy says that her position as director of patient safety, reliability and infection prevention is strong evidence of her hospital’s advocacy for patient safety. She holds a master’s degree in health care quality and patient safety from Northwestern University (2013) and sits on the board of the National Association of Healthcare Quality. She’s well-equipped to introduce new safety ideas and best practices.
“What gives me the greatest satisfaction is that this is not a one-woman show,” said Curdy. “I’m just the conductor. We’ve all put our egos aside to focus on safety. We do pilot projects, measure results and roll out millions of initiatives it seems, but I’m just the conductor. Everyone is on board.”
Curdy and many hospital safety specialists have borrowed high-reliability principles from other risk-laden industries such as nuclear energy and the airlines. “If you assume errors will happen, and look where they can happen, then improve those processes, you’re more likely to prevent errors,” she said.
The operating room uses the World Health Organization’s Surgical Safety Checklist promoted by Dr. Atul Gawande, not because operating teams aren’t highly intelligent and well-trained, but because small things can get overlooked in the fast-paced environment. “Small things can cause errors and in the OR when errors are caught, lives are saved,” said Curdy.
Bar coding on medication adds another layer of safety, as does implementing distraction-free zones to make sure that nurses preparing medications aren’t interrupted. Interdisciplinary rounding with patients, a career ladder system of self-governance giving nurses a voice in operations, daily safety huddles for leadership and every unit, close scrutiny of central lines and catheters to reduce infection and reporting safety data to staff are all part of DeKalb’s safety vigilance. Recently 48 leaders from across the hospital went through Six Sigma training to learn new tools for defining problems, removing barriers and reaching better outcomes. “We are practicing process improvement continuously,” she added.
Piedmont Atlanta Hospital
Pam Falk was a medical technologist working in a microbiology lab when a nurse asked what kind of bacteria she had found and took that information back to her unit. Seeing someone use her data to affect practice inspired Falk to earn a master’s degree in public health and hospital epidemiology, and to become certified in infection control.
“My approach to infection prevention is scientific and academic. I’m constantly reading the literature and implementing new safety initiatives to reduce errors and hospital-acquired infections,” said Falk, manager of infection prevention.
All management participates in a safety huddle daily at 11:00 to review safety indicators and problems from the past 24 hours. Her infection prevention team of five members participates in patient rounding to observe, collect information and raise questions.
“You can’t have a catheter-associated infection or a central-line bloodstream infection, unless you have a catheter or a central line, so we assess every patient every day to make sure they are really needed,” she said. “The staff might ask if a peripheral IV line could be used to administer medication, for instance.” With nurses actively engaged in assessing and analyzing this area of care, almost every unit has reduced its catheter days to below the national average and the hospital is seeing fewer infections.
Falk says that there is always new research regarding patient safety. “We use flyers and fact sheets to disseminate important information about new products or viruses to our leadership safety huddle,” she said.
Knowing the critical importance of proper hand hygiene, the hospital recruits some staff members to secretly monitor and record hand-washing activity in their areas.
Falk says that improvements stem from her team having a great questioning attitude. “We are always asking ‘how does that work?’ and ‘could we do it better?’” she said. Knowing that safety initiatives take extra effort and team work, she and her team recognize and celebrate every improvement.
WellStar Health System
About six years ago, WellStar employed Healthcare Performance Improvement, a health care safety consulting firm, to help them create a comprehensive patient safety culture.
“We have adopted a whole platform of strategies to optimize human performance and reduce errors,” said Marcia Delk, MD, MBA, senior vice-president of safety and quality, credentialing and chief safety officer. “Establishing a safety culture environment takes a team approach. It starts with teaching safety science principles to everyone from top leadership down, so we do everything with safety in mind.”
Training is ongoing, as things are always changing in a hospital. “Changes include new staff, new services, new technologies, new medications, new protocols, new products and changing requirements. We have to figure out how to introduce those changes safely into the environment,” said Vicky Hogue, MSN, RN, chief nursing officer WellStar Paulding and vice president of patient services.
It starts with giving everyone a common safety language that can be used in many different situations, said Delk. “Communication is crucial and teams need a way to get the right information quickly to prevent errors.”
ARCC is one way that empowers WellStar employees to speak up when confused or concerned about an aspect of care. ARCC stands for Ask a question, Request a change, voice a Concern, and call in someone higher up the Chain of command. “Anyone can stop the line and we respect, recognize and appreciate those who do, because it prevents errors being made,” said Hogue.
Daily safety huddles, making everyone aware of safety event statistics and having a safety coach in every unit are other best practices. Safety coaches focus on safety issues, provide positive reinforcement and give out safety awards. Mission critical safety information is passed to safety huddles through Safety WINKs or What I Need to Know about new medications, MRSA or fall risks.
Hogue is proud that every aspect of the WellStar Paulding Hospital was designed with patient safety in mind. “We designed the rooms to keep clutter down to reduce falls and chose non-skid flooring to reduce fall injuries,” said Hogue. “Bedside rails light up at night and hand-sanitizers are equipped with radio-frequency chips to monitor hand hygiene,” she said. An ultra-violent light device is used to clean hospital rooms, adding an extra layer of safety to the decontamination process.
In her training, Delk brings home the impact of embracing safety principles. “She prints the names of patients who have suffered a safety event on a slide,” said Hogue. “Those who lost their lives are printed in red. The first slide was covered, but every year we see fewer names.”
“I’m proud of our accomplishments, but most proud that we have 12,000 people focused on healing patients and creating a safe environment,” said Delk.