SAN DIEGO — A panel of otolaryngologists was assembled onstage to discuss how their field could make changes to improve patient safety when Ravi Samy, MD, associate professor of otolaryngology at the University of Cincinnati in Ohio, asked a question: Would you rather work with a top-performing, A-level healthcare team in a B-level system? Or would you rather work in an A-level system with a B-level healthcare team?
Explore This IssueMarch 2020
Dr. Samy knew his answer: He’d choose top people over a top system.
“I’d rather work with phenomenal people around me, knowing that the system might not be at its best,” he said.
But in a thought-provoking discussion here at the Triological Society Combined Sections Meeting, in which physicians were forced to consider their own vulnerabilities as well as those of their broader environment, the other panelists had a different take. You and your colleagues might be top-level performers, but what if you have an off day? they asked.
Capt. Ryan Carron, a naval aviator who became a patient safety advocate after losing his son shortly after birth following a series of medical errors, suggested that it’s unreasonable to expect that someone will always perform well.
“Have you ever been a B person, or perhaps a C person?” he asked Dr. Samy, who responded, “Absolutely.”
“We all have external stressors,” said Capt. Carron, who draws from his experience in the military to describe how medical systems can better protect patients. “We all have times when we are not A personnel. I think we also have people on our team who are, period, not A personnel. For me, … I want an A system.”
Chad Zender, MD, associate chief medical officer at the University of Cincinnati, agreed.
“If we’re going to function in healthcare and provide the care we need, we have to have the systems built to work with the people who are available to us,” he said.
Dr. Zender said that there are a variety of environments or problems that can lead to catastrophic medical errors. Sometimes there is a good plan and a good outcome, and sometimes there are just bad plans with bad outcomes. But he drew attention to the area in the middle—which he called “unintentional variation”—in which the plan is good but doesn’t account for unintentional events.
“I’m not talking about taking away the ability to have intended variation, where you want a different antibiotic [than the standard] because the MRSA screen was positive,” he said. “We just don’t want the wrong dose or the wrong antibiotic to show up in the room accidentally.”
In a word, the idea is reliability.
“We want a highly reliable process in healthcare that allows us to provide the health services intended consistently and failure-free over time,” he said.
I’ve seen incidents (with) the wrong procedure on the wrong patient on the floor, and the nurse wasn’t even in the room or asked if that patient was supposed to have that procedure done. —Chad Zender, MD
After an error, basic steps such as attempting to work harder next time, offering feedback to those involved, or promoting awareness on patient safety will not do much to ensure better outcomes in the future, Dr. Zender said. Those steps ultimately won’t overcome factors like fatigue and competing demands that likely helped lead to the mistake in the first place. More fundamental changes to the system are needed, he said.
“The system is built to give us what we get,” he said. “And if we don’t change the system, we can’t just beat on the people in it to get a better outcome.”
Beyond those basic steps are decision aids and reminders; making a desired action the default requiring an un-click, such as the preferred antibiotic for a certain procedure; and redundancy in reviewing.
“I’ve seen incidents (with) the wrong procedure on the wrong patient on the floor, and the nurse wasn’t even in the room or asked if that patient was supposed to have that procedure done,” Dr. Zender said.
The highest level of reliability involves a “focus on failure”: turning errors into changes that improve the system, he said.
“There’s winners and then there’s learners, and I think when your mindset really transforms to that, we get to the point where we can look at failures not as a shameful thing because we’re supposed to be superhuman, but there are actually things where we can get better,” he said.
The panelists discussed barriers to improving quality and safety.
Dr. Zender said one of them is having the right data.
“Changing people often requires them to understand what the impact is,” he said. “Without the data, it’s hard to get people to change, as much as they say they want to. Change is difficult—keeping the focus on our patients will help us get the results we want.”
Capt. Carron referred to the “get-real” quotient: The farther leaders get from the action of clinical care, the harder it is to generate change. He pointed out that he still participates in training with junior personnel, which involves flying together in a Navy helicopter.
“You’ve got somebody with 25 years of flight experience flying with somebody with two years of flight experience,” he said. “And that creates that forcing bond of communication that’s probably better than you get from any PowerPoint or any briefing that you get throughout the week.”
Albert Merati, MD, chief of laryngology at the University of Washington in Seattle and vice president of the Triological Society’s Western Section, said that before a surgery, having the team members introduce themselves by name and position helps create an environment in which communication—and potentially error prevention—is encouraged.
“When the anesthesia tech speaks up, he or she is more likely to speak up again if there’s a problem if they’ve introduced themselves,” he said. “And as leaders, I think it’s important to create that environment.”
Thomas Collins is a freelance medical writer based in Florida.