Patient Safety on the Wane? (Elizabeth Hofheinz @ OTW)
When Dr. James Herndon, a former president of the AAOS and Chairman Emeritus of orthopedics at Harvard, had surgery recently, he wasn’t taking any chances. A resident came in and did the “sign your site” drill, at which point Dr. Herndon said, “Go get the surgeon…I want his signature too.”
Why the extreme caution? Because Dr. Herndon has the facts. And the overarching, disturbing fact is that patient safety among orthopedic surgery residencies has declined. Dr. Herndon, whose article on this topic was recently published in theJournal of Bone and Joint Surgery, explains, “We surveyed 169 residents and found that despite having been exposed to formal educational events on safety in the last ten years, the patient safety climate has decreased. Unfortunately, the culture of many hospitals is such that they don’t want to recognize mistakes. Couple that with the fact that most doctors don’t believe that near misses and mistakes are as common as they are, and the fact that people don’t often recall their mistakes, and you have a good picture of the challenge we’re up against.”
To assess the status of safety, Dr. Herndon and his colleagues looked to the skies. An OR is a high pressure environment…so is an airplane cockpit. If the plane goes down, it’s all over. At the risk of stating the obvious, pilots are highly motivated to take every appropriate safety measure. “We used the Patient Safety Climate in Healthcare Organizations (PSCHO) questionnaire, a tool that was adapted from a survey that is used with aircraft fighter pilots. The PSCHO was developed by the Patient Safety Culture Institute at Stanford University and the Palo Alto Veterans Affairs. For this study, conducted over six years, we used a version modified by George Bilke, M.D. of the Dartmouth-Hitchcock Medical Center.”
And their eye-opening finding?
“Whereas 6% of aviators assessed safety as being a problem,” says Dr. Herndon, “between 13 and 15% of orthopedic residents answered questions implying that safety was a problem. So our problems with safety could actually be twice as high as those of military pilots.”
Delving into the survey itself, Dr. Herndon states, “We examined several safety related topics, communication up and down the chain of command, management’s ability to respond to safety issues, safety reporting, and concerns of safety at the point of care.”
Perhaps most alarming was our finding that en masse respondents were unwilling to report unsafe situations because they were afraid of retribution.
“And this is an issue that exists across the medical world—not only orthopedics. But we still have to find ways to deal with this. One possibility is to place boxes around the hospital where people can report situations anonymously.”
An example of a communication error is as follows: a doctor who is leaving his/her shift says to a colleague: “Surgery went well. I just gave Mrs. Jones the pain medication. I’ve got to go now.” The physician or nurse receiving the information may have important questions, but, sensing that the departing doctor isn’t open to inquiry, thinks, “Well, I guess everything is in the chart.” Dr. Herndon: “One thing we assessed was the degree to which good communication flow exists down and up the chain of command regarding patient safety issues. The major issue here is the frequency in the change of providers. There are more personnel involved in one person’s care than ever before. Some patients have five or ten doctors involved, not counting nurses and other personnel. That is a lot of room for communication errors.”
“The point at which residents sign in and out of shifts is critical because that space of time is ripe for mistakes. Fatigued residents are being interrupted by the staff and they are getting paged to answer questions, etc. This could lead to someone forgetting to chart an issue, or be less comprehensive than they normally would be. If the doctor leaving the shift appears hurried, he may signal to those still on duty that he is not especially open to questions. And one alarming study—one conducted with pediatric residents—found that despite the residents’ perception that their patient handoffs were solid, they actually failed to note a diagnosis nearly 40% of the time.”
Sometimes, a culture of safety collides with a wider cultural phenomenon of wanting to be seen as someone who can “tough it out.” “One of the issues we looked into was whether or not senior management would readily restrict personnel who were under a lot of stress. The residents in this survey overwhelming said, ‘We don’t see that happening.’ In many cases it may be that surgeons don’t want to reveal that they are overly stressed, thus management wouldn’t be in a position to respond. Whatever the situation, it often takes some form of acting out on the part of the surgeon until management does something about the problem.”
A scientist, Dr. Herndon doesn’t give in to suspicions…but he wonders when the evidence hints at things. And now, he just may be thinking that students are taking notes in invisible ink. Dr. Herndon explains, “The fact that patient safety was formally and repeatedly emphasized over several years, and that things actually got worse, makes me wonder if something else is going on. I have come to believe that even though residents sit in lectures and hear all the right things, once they begin their workday in the hospital, there is a shift of emphasis to what is unspoken.”
“I think that these young trainees fall into step with the ‘hidden curriculum,’ i.e., how people around them behave. They learn one thing in lectures and go to the floors and see their superiors doing something else. What are they to think?”
If, that is, they can think clearly at all. “Resident burnout is a real issue, and is one that is strongly related to surgical errors. Brigham and Women’s Hospital just published a paper on surgeons and fatigue (which is just one aspect of burnout). Their findings led them to say that if a surgeon has been up 24 hours before surgery (for example, they were up all day and all night Wednesday, and have an elective case Thursday morning) then they have an obligation to tell the patient that they have not slept in 24 hours. Many surgeons don’t schedule elective surgeries in such a situation, but that is not always true. You can imagine the disincentives…scheduling problems for the doctor, the patient, and the hospital, loss of money for the hospital. Ideally, hospitals would have a mechanism to make up for such a situation.”
Those fighting the good fight say there is hope. “Change has come,” says Dr. Herndon, “and things will continue to evolve as we obtain more evidence of what is working and what is not. We have improved systems that can help avoid errors, such as color coding of medication vials. In the future, the most important weapon we have in the fight for safety is the checklist. Those institutions that have implemented checklists have demonstrated a significant reduction in mortality and surgical errors.”
“Many organizations are involved in advancing patient safety, including the World Health Organization, which has extensive pre-, intra-, and postoperative checklists. Nationally, both AAOS and The Joint Commission support preoperative time outs…brief periods where anyone in the OR can raise concerns before the surgery gets underway. As for the ‘Sign Your Site’ program, AAOS has been a major leader in making that more common around the country.”
Checklists…they sound quite helpful. But they take time. And, says Dr. Herndon, there is another reason that surgeons may not want to pick up that pencil. “Some doctors are going to be concerned that if they forgot to check something off then that could result in a malpractice suit. To my colleagues I say, ‘Prepare yourself…mandatory checklists are not too far down the pike.’”
To those who groan, Dr. Herndon says that such a systematic approach may be the only way to rectify such a widespread problem. “Earlier this year a paper on adverse events was published in Health Affairs. The study was undertaken under the auspices of the Institute for Healthcare Improvement, a nonprofit headed at the time by Donald Berwick, the new director of the Center for Medicaid and Medicare Services. The researchers looked at two ways that adverse events are tracked: the first is voluntary reporting and patient safety indicators. When that was compared to chart reviews they found that traditional reporting (voluntary and safety indicators) missed 90% of the adverse events. Chart reviews were much more effective at catching patient safety issues.”
To hospital administrators who may not be ready to deal with this issue, Dr. Herndon says that there is incentive for them…budgetary incentives and marketing incentives. “One study examined heart attacks, respiratory problems, and heart failure, and found that those organizations that had a safety culture at every level of personnel, had significantly lower readmission rates. That is better for the bottom line, not to mention the reputation of the hospital.”
And these issues are being closely watched by external parties. “The media is routinely reporting what hospitals are doing well, and where they are coming up short. In addition, insurers are providing external pressure. One large national insurance company has recently determined that instead of standard payments to hospitals, going forward they are only going to pay hospitals based on quality. Hospitals that don’t meet their criteria will not receive the yearly increase in payments they are accustomed to. This will be replaced with an increase based solely on quality performance measures. Their gold standards? Readmission rates and the use of checklists.”
“All doctors must recognize that medical errors are a very real problem. We are all human and make mistakes…but we must go through the process of learning how our errors develop. My hope is that more orthopedic surgeons become active in attempts to change the culture and systems so that errors don’t occur. Have the heart, as it were, to step forward and say, ‘There was a near miss.’”