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Voices for Safer Care

Insights from the Armstrong Institute

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Preventing Patient Harm

Coming home

Last week, my family returned from a vacation in Jamaica. The kids had spring break and it was great to get away with them. Upon returning to the U.S. and after clearing passport control, the customs agent said “welcome home.” No doubt they are trained to say this; I hear it every time I travel internationally. Nevertheless, those words always warm my heart and make me smile. They reflect for me a national culture, a set of values and beliefs about how we will behave. Welcome home to the U.S. reminds me that we live under the rule of law, that we are all afforded due process, that we have freedoms to voice our concerns, to practice our religions, to vote.

As we drove home, we rounded the corner and our house came into view. Again warm feelings flooded me. Seeing my home, I reflected on the deeply held beliefs of love, of support and nurturing, of forgiveness, of warmth and comfort—the culture of our home.

Two days later, on Monday, I returned to work, starting as the attending physician in the ICU. As I walked into the ICU, I thought about the culture we have created there, the sets of norms and beliefs that govern behaviors, my largely hidden assumptions about the organization and my colleagues.

Clinicians, when you walk into your clinical or hospital, what kind of culture are you part of? Is this a place where patients are the “North Star,” their needs guiding all of your work? Is it a place where clinicians’ egos are put aside and they focus on what is right rather than who is right, where we commit to practice evidence-based medicine, to work as a team, to continually learn and improve? Is it where staff seek to identify and mitigate patient safety hazards, respect the wisdom of frontline workers and empower them to improve? Is it a place where we see our differences as strengths rather than weaknesses, where we support each other, hold each other’s hands when we are down, laugh and cry together?

Read More »Coming home

Dreaming the dream

Susan BoyleThe video of Susan Boyle’s debut on Britain’s Got Talent is well worth watching. She walked on stage, wearing a frumpy dress, overweight and awkward. Members of the audience snickered and rolled their eyes as this 47-year-old told the judges that she wanted to be a singing star. I suspect she had her own doubts. Yet she had the courage to try. She believed in herself and stunned the audience with her voice.

Susan’s story is typical of so many personal journeys. We face skepticism from others, and we are filled with self-doubt. Sometimes we listen to those little voices whispering: You cannot do this. Yet when we overcome the doubts, we are often successful. If we give into those voices, we will surely fail.

This same self-doubt exists in patient safety. I know because I had plenty of uncertainty about my ability to reduce patient harm. More than a decade ago, we decided to reduce central line-associated bloodstream infections on one intensive care unit. We doubted it was possible and whether we could have a role in reducing harm. Most of the physicians thought it couldn’t be done. Sick people get infected, they said. These infections just happen. In our own way, we felt frumpy and awkward.

Initially, we did not debate whether we could stop these infections. We focused on consistently following those practices shown by evidence to reduce them. We had been complying with those practices just 30 percent of the time. Our clinicians agreed that we would follow a checklist to help ensure 100 percent compliance and then see what happened to our infections. As compliance rose, the rates went to nearly zero, and the doubts disappeared.

Read More »Dreaming the dream

Why can’t the ICU be more like a cockpit?

cockpitIn the world of patient safety, we’re constantly reinforcing the importance of teamwork and communication, both among clinicians and with patients. That’s because we know that patient harm so often occurs when vital information about a patient’s care is omitted, miscommunicated or ignored.

Yet for all we do to improve how humans work together, clinicians compete against an environment in which there is very little teamwork or communication among the technologies that they need to care for patients. And there’s little that clinicians or hospitals alone can do about it.

Take, for example, the plethora of alarms from cardiac monitors and other devices that compete for clinicians’ attention. Vendors act as if we are in an alarm race, with each making their devices’ beeps more annoying but no clear prioritizing of the most important alarms. A study on one 15-bed Hopkins Hospital unit a few years ago found that a critical alarm sounded every 92 seconds. As a result, nurses waste their precious time chasing an ever-growing number of false alarms—or becoming desensitized to false alarms and ignoring them. Across the country, this has had tragic consequences, as patients have died while their alarms went unheeded. (Read a 2011 Boston Globe series about this issue.)

In most other high-risk industries, such as aviation and nuclear power, technologies are integrated. They talk to each other, and they automatically adjust based on feedback. Indeed, because of systems integration, pilots fly a small amount of a flight, and even in some treacherous situations, they hand over the reins to the autopilot. Although Southwest Airlines or the U.S. Air Force can buy a working plane, you cannot buy a working hospital or ICU. You must put it together yourself.Read More »Why can’t the ICU be more like a cockpit?

To gauge hospital quality, patients deserve more outcome measures

Central LinePatients, providers and the public have much to celebrate. This week, the Centers for Medicare and Medicaid Services’ Hospital Compare website added central line-associated bloodstream infections in intensive care units to its list of publicly reported quality of care measures for individual hospitals.

Why is this so important? There is universal support for the idea that the U.S. health care system should pay for value rather than volume, for the results we achieve rather than efforts we make. Health care needs outcome measures for the thousands of procedures and diagnoses that patients encounter. Yet we have few such measures and instead must gauge quality by looking to other public data, such as process of care measures (whether patients received therapies shown to improve outcomes) and results of patient surveys rating their hospital experiences.

Unfortunately, we lack a national approach to producing the large number of valid, reliable outcome measures that patients deserve. This is no easy task. Developing these measures is challenging and requires investments that haven’t yet been made.

Read More »To gauge hospital quality, patients deserve more outcome measures

What I learned from listening to a patient

ListeningI was reminded again recently of how important it is to sometimes just sit back and listen to what our patients have to say. Every month, as part of our hospital-wide patient safety efforts, I meet with staff and interview patients, seeking to learn how we can improve the care we provide to them.

A young patient shared two stories with me, one telling me how we get it right and one reminding me how we sometimes get it wrong, even without realizing it. She was nervously awaiting a procedure in Interventional Radiology when a nurse sensed her anxiety and called in a child life specialist. The specialists came and significantly helped relieve the patient’s suffering. She listened to the patient, offered a comforting touch, and provided her age-appropriate reading material and Sudoku puzzles, a brilliant though infrequently used intervention. If anything could take your mind off of your illness, it is Sudoku.

What was amazing was that after all the patient had been through—weeks in the hospital, countless procedures, scores of clinicians—what she remembered was the nurse’s act of kindness by caring enough to call the specialist. The patient reminded me that though we can cure disease sometimes, we can relieve suffering always, often with nothing more than a kind word, a gentle touch or a warm smile.

As I listened, the patient, along with her mother, went on to tell me more. They told me how the patient has complex allergies and that her mom knew her disease better than any clinician. They had lived with the disease for a decade. Yet at times, neither the patient’s mother nor the patient felt they were being heard by the doctors. The mom expressed frustration that clinicians often dismissed her concerns and discredited her knowledge.

Read More »What I learned from listening to a patient

A safety checklist for patients

checklistFar too many patients are harmed rather than helped from their interactions with the health care system. While reducing this harm has proven to be devilishly difficult, we have found that checklists help. Checklists help to reduce ambiguity about what to do, to prioritize what is most important, and to clarify the behaviors that are most helpful.

The use of checklists helped to reduce central-line associated bloodstream infections at The Johns Hopkins Hospital, in hospitals throughout Michigan, and now across the United States. Clinicians have begun to develop, implement and evaluate checklists for a variety of other diagnoses and procedures.

Patients can also use checklists to defend themselves against the major causes of preventable harm. Here are a few you can use:

Health care-associated infections

  • Ask about your hospital’s rates of central-line associated bloodstream infections in the intensive care unit. The best hospitals use the definitions provided by the Centers for Disease Control and Prevention and have rates less than one infection per 1,000 catheter days. A rate above three should cause concern.
  • Whenever clinicians enter your room, ask if they have washed their hands. Request that visitors also wash their hands often. Washing can be with alcohol gel or soap and water.
  • If you have any type of catheter, ask every day if that catheter can be removed.

Identification errors

  • If you are admitted to the hospital, check your ID bracelet to make sure all information is correct. Staff should use this bracelet to confirm your name before any treatments or tests.
  • If you are making an outpatient visit, staff should ask you to confirm your name and another unique identifier, such as your date of birth, before treatments or tests.
  • Verify that blood and other specimens taken from your body are labeled in front of you.

Read More »A safety checklist for patients

Counting our patient safety blessings

My daughter just asked me what I was thankful for this Thanksgiving. As I reflected on the blessings in my family and personal life, I also thought about what I was grateful for in patient safety. While progress has been slower than any of us would want, we certainly have many things to count:

Patient- and family-centered care is getting long-overdue attention. About two years ago, nurses on one unit at the Johns Hopkins Children’s Center began conducting  shift-change reports in patients’ rooms, rather than in the hallway, so that patients and family members have the chance to ask questions and get the most up-to-date information. More hospitals are including patients on committees. These are small changes, but they represent a larger acknowledgement of the importance of building care around patients’ needs and to seek their wisdom.

Clinicians are increasingly engaged in the work of patient safety. In the past they have largely stayed on the sidelines or have pushed back—often appropriately—against regulatory mandates, interventions or measures that are not informed by science. Yet clinicians did not step forward to take the lead. Now they are. Professional societies, physicians, researchers, nurses, want the science to be good, the measures to be wise, and the interventions flexible enough to fit into their local context. Over the last two weeks, I had calls with several professional societies planning safety programs. At Hopkins, more than 100 faculty members recently showed up at a meeting for those interested in conducting patient safety research.

Read More »Counting our patient safety blessings