One example of this concerns an element in the policy for discharge bundles that institutions establish to better manage transfer of care. When lab results become available only after a patient’s discharge, it increases the risk for delays in diagnosis. Electronically placing the test results into the primary care physician’s e-mail inbox helps to “close the loop,” says Dr. Nagamine. “That information gets to somebody, and we’re clear on who that somebody is. We are putting in place those types of interventions—which are really the low-hanging fruit.”
Culture Change
Opening up about adverse events and providing feedback creates a different awareness about the risks surrounding the event.
“The look-alike, sound-alike medications are an example,” Dr. Nagamine says. “I went up to the unit and said, ‘A nurse recorded that she almost gave hydralazine instead of hydroxyzine—has that ever happened to you?’ The first three nurses I asked said, ‘Yes,’ ‘Yes,’ ‘Yes.’ Until I ask these types of questions, I don’t know. And until you can make it safe for your staff to talk, you will not have good information.”
Although this is the approach most of the safety world and quality world is embracing, it is not how most clinicians on the frontline view it.
“We are trying to educate people about a framework in which to think about this,” says Dr. Nagamine. “It is not constructive to point fingers, but it is important to give people feedback about how the event happened. It is far more constructive to look at the entire system and ask, ‘How did we fail here? What was your piece of it? What was the system’s piece of it?’ ”
Because of the connection between litigation and adverse events, changing the culture is a complex imperative. But providers must recognize that systems failures are involved in about 75% to 80% of medical malpractice cases—whether that involves communication breakdowns, inadequate availability of information, or a host of other factors. The individual, environment, and organization are linked.
Reducing negativity and sensitivity around the terms associated with error and reframing thinking toward prevention are important.
“There is a richness of information that comes once you change the culture from blaming to fixing,” says Dr. Nagamine. Providing feedback to frontline practitioners is key, as is thanking those who report. “It increases providers’ awareness about where the hot spots and vulnerabilities are and how to stay out of trouble. Simply by giving them information about an event raises their awareness of the magnitude of certain types of issues,” she explains.
When Dr. Nagamine led a safety initiative on the ICU floor consisting of human factors training and a new system for reporting events, the number of reports “went through roof,” she says. “My new problem was not that people were not reporting; it was being overwhelmed with the information that was coming in. We were able to create a culture of safety that made it safe to report and consequently had much better information from which we could devise prevention strategies.”
SHM, in planning to co-create standards for focused practice with the American Board of Internal Medicine, intends to promote the standards of professionalism along with other standards. The issue of personal accountability, although a part of that, has been less of a focus to date. In the future, all institutions may have technology hospitalists can use to learn whether the discharge diagnosis was correct in the months and years that followed. Will the culture be emotionally ready to handle what technology can offer?
“We will need to own it when things go well and when things don’t go well or when we are wrong,” says Dr. Halasyamani. “We need to be able to investigate the distribution of the reasons for misdiagnosis, determine how many of those problems are systems issues, and devise strategies to address them.” In a sense, she says, everything can be viewed as a system issue unless actions are egregious and malicious.