Creating a Culture of Patient Safety is Continuous, Collaborative Process
Written by: Leah Jeunnette, Ph.D.(c)
In 1999, the Institute of Medicine demonstrated the staggering statistic that the number of people who die each day from medical errors is the same as if a jumbo jet were crashing every day. That illustration made the issue of medical errors and patient safety a recognizable issue that needed to be addressed. For many decades, people had trusted healthcare to benefit its patients, not cause harm, but this dramatic number created fear and mistrust of not only the industry as a whole, but of individual healthcare professionals. As a result, patient safety came into sharper focus and improvements were made. Although those numbers from the IOM have changed, medical errors still take place and patients are still harmed, even if only accidentally, and when patients are harmed, the clinicians and healthcare organizations are harmed, as well. Creating a culture of patient safety and actively maintaining it are continuous, collaborative processes, not fads or occasional campaigns, which demand ongoing attention, commitment, and demonstration.
Positive stories demonstrating a commitment to patient safety that make the news are few and far between but they need to be sought out and publicized, too. Unfortunately, even as many organizations work at creating a culture of patient safety, negative, horrible stories still capture headlines discouraging us with the realization that some of these adverse events are recurring and some could have most certainly been prevented. Go ahead, click on any news media site (and particularly their pages covering health or medicine) — they are not hard to find.
For instance, take the case of Jennifer Melton’s newborn son Nate. In December of 2015, a doctor at University Medical Center in Lebanon, Tennessee, reportedly performed a tongue clipping, but on the wrong infant. Little Nate was taken into surgery and had his tongue clipped needlessly, erroneously. This case of medical error involved several components worthy of note in the patient safety discussion.
First: bringing the wrong infant into the surgery. Neither surgical nor post-partum nurses nor doctors accurately checked (nor double-checked) to confirm that they had the right patient. Most of the time, they ask patients for name and birthdate, but in the case of infants, who cannot speak up for themselves, parents should be asked to confirm. In this case, the infant was taken from the nursery without checking with the mother.
Second: the apology. When the doctor did apologize, it was over the phone, in a non-personal way. The act of sincerely apologizing (that means showing that you really do care) and the legal ramifications of taking the blame can be problematic and definitely uncomfortable, but probably necessary if the patient and, in this case, most especially the family are going to get over any feelings of distrust, victimization, abandonment, and fear.
Third: the sometimes-difficult intersection of nurses who are employees and physicians with privileges who are non-employees. The physician in this case was employed by another entity, but with privileges at this organization. However, the nurses are under the authority of the physician in the OR, and issues of procedural differences, competing loyalties, and even moral distress may arise as a result, any of which could lead to problems for the patient.
For any issue of medical error, there should be transparency of how this issue is going to be addressed, not just for the patient, but for the organization, too, regarding resolution and any changes going forward. There needs to be better collaboration between all team members (i.e., all staff, contractual clinicians, and administrators) on creating a culture of patient safety where patients actually feel safe and are safe. This is not done overnight, not through a single promotional event; it takes commitment, time, effort, resources, and specialized training to accomplish and maintain.
We would like to assume that everyone (including ourselves) acts ethically and would never cause any type of intentional harm; however, we know that there are healthcare professionals who have committed intentional harm against patients, as well as those who unintentionally harm patients. Simply taking inappropriate shortcuts can bring unexpected harm to the patients. While the healthcare professionals never set out to hurt Nate, he was unnecessarily harmed. Hopefully, Nate will be ok and stay ok, but the fallout continues, as there has been a glaring breach of trust and safety that needs to be resolved and communicated. Often, the headlines only cover the harms and their sensational impact, but not the remedies, which need to be well thought out and well publicized, too, if trust is to be restored.
I’m sure that many of those who saw the horrifying news item (like me!) would like to ask a few questions, like is there a system of proven checks and balances; is there a new method of checkpoints to prevent a specific issue; is an outside auditor being brought in to assess the current culture or a safety expert to make recommendations? Most of us may never hear how this case will be settled or what actions the University Medical Center in Lebanon, Tennessee, is taking to ensure that patients are safe and that this issue never happens again. Still, I’m thinking that many of us are looking for some assurances!
Kohn, L. T., J. M. Corrigan, and M. S. Donaldson. “To Err is Human. Building a Safer Health System. Committee on Quality of Health Care in America. Washington, DC: Institute of Medicine.” (1999).