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
Explore This Issue
March 2020
Fundamental Changes
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.”