Learning from Experience to Improve Patient Safety
In seeking to improve safety, one of the most frustrating aspects for patients and professionals alike is the apparent failure of health-care systems to learn from their mistakes. Too often neither health-care providers nor health-care organizations advise others when a mishap occurs, nor do they share what they have learned when an investigation has been carried out. As a consequence, the same mistakes occur repeatedly in many settings and patients continue to be harmed by preventable errors.
-World Health Organization, 2005
In complex healthcare systems, a majority of problems are caused by breakdowns in system and processes, not by poor practices or incompetent practitioners. The World Health Organization (WHO) has recognized that “We know that most problems are not just a series of random, unconnected one-off events. We know that health-care errors are provoked by weak systems and often have common root causes which can be generalized and corrected. Although each event is unique, there are likely to be similarities and patterns in sources of risk which may otherwise go unnoticed if incidents are not reported and analyzed” (World Alliance for Patient Safety, 2005). One of the Oregon Patient Safety Commission’s primary goals is to identify these events and learn from them in order to improve the healthcare system.
Patient Safety Then and Now
Each year, the National Patient Safety Foundation leads Patient Safety Awareness Week, an annual education and awareness campaign for healthcare safety. This year, Patient Safety Awareness Week runs Sunday, March 4 through Saturday, March 10 with the theme Be Aware For Safe Care. The theme encourages both healthcare providers and patients to take advantage of opportunities to learn how we can all contribute to making healthcare safer. In honor of Patient Safety Awareness Week, we reflect on some of the patient safety movement’s beginnings and one of the most critical factors necessary to improve patient safety – establishing a culture of safety.
Improving Patient Safety Through Provider Communication
A patient was given 30mg of Toradol in the operating room (OR); however, the medication was not reported to the recovery nurse. During the patient’s first 15 minutes in the post-acute care unit, the patient was restless and disoriented and complained of pain. One recovery nurse attended to the patient while a second recovery nurse retrieved Toradol per the post-operation orders. The first nurse drew up the Toradol and administered another 30mg to the patient, not knowing that the patient had already received Toradol in the OR. After the patient was resting and calm, the first nurse read through the chart, discovered her mistake, and immediately informed the anesthesiologist and surgeon.
-Event reported to the Commission
The Agency for Healthcare Research and Quality (AHRQ) recently released the sixth annual edition of the Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report, which provides survey results from 567,703 staff from 1,128 U.S. hospitals. The survey revealed that handoffs and transitions were the second most commonly identified area needing improvement. AHRQ reported that “only 45 percent of hospital staff have positive perceptions of handoffs and transitions across hospital units.”
Engaging Patients & Families for Safe, Quality Care
A 71 year-old male was discharged home following a colonoscopy. A short time later the patient started having progressively severe abdominal pain and went to the ED where a CT scan revealed evidence of a bleed and a slightly enlarged spleen. It was discovered that the patient had not discontinued his Coumadin prior to surgery as indicated in his pre-surgical instructions. He was admitted for monitoring and received six units of blood.
- Event reported to the Commission
Breakdowns in communication were one of the top three leading root causes of sentinel events reported to The Joint Commission in the United States between 2004 and 2011. These communication breakdowns occurred among healthcare professionals and also between healthcare professionals and patients or families. The Oregon Patient Safety Commission’s aggregate summaries of events reported in 2010 by Oregon hospitals, nursing homes, and ambulatory surgery centers identified similar trends in Oregon. In hospitals, communication concerns were a contributing factor in two out of every three events reported (66% of the time). In both nursing homes and ASCs, communication was among the top three reported factors that contributed to adverse events.
