audit conference

audit conference
audit conference

Wednesday, December 1, 2010

Safety culture

In recent years patient safety has become both a national and international interest. There is increased emphasis across the world on patient safety in policy reform, legislative changes and development of standards of care driven by quality improvement initiatives.

Safety culture was introduced as a specific concept of organisational culture in the aftermath of the Chernobyl nuclear reactor accident in 1986. It was found that the primary cause to this accident was by human error rather than technical failures. That human error was not due to shortcomings of the individual but rather a failure of the culture to realise that understandings of the inevitability of human error. 

What has to be accepted is that we live in an imperfect world: as human beings we all are prone to making mistakes and that no one system is perfect. However, when working in the delivery of healthcare we owe it to our patients and fellow colleagues to do the best we can. The key condition for safety in our high-hazard industry in healthcare is to support safe practices among ourselves: a culture that collaborates with open communication, teamwork, acknowledges mutual dependency and lastly the primacy of safety as a priority at all levels. To accept that mistakes and failures do occur and it gives us the opportunity to use the incident to reflect on what it reveals about the gaps and inadequacies in the healthcare system.  

In reality health care providers are usually more interested in the accountability of individuals, assigning ‘blame’ for mistakes persons working on the ‘front line’. According to the research describes how healthcare has two main obstacles to improving healthcare safety: firstly a belief in ‘training perfectly’, that after long and demanding training healthcare professionals expect - are expected - to get it right! And the second point that there is a tendency to stigmatize and sanction fallibility (error is equated to incompetence) these two traditional influences have made it difficult for healthcare providers to admit their mistakes and learn from the mistakes that have happened.  

 Another aspect is that healthcare providers often encounter errors during their clinical practice for example the infection rate on CBI (catheter – related blood stream infections) they may regard the occurrence of infection as an acceptable level whereas proper hand washing could eliminate such infections. Working in a hierarchically organisation of accountability and responsibility does not lend its self to reporting problems. A problem could be taken as a personal attack rather than a constructive opinion that may help the organisation by improving the present system. 

It is important to access the safety culture of the organisation in order to develop patient safety. The WHO launched a series of activities in highlighting topics into patient safety in order to identify poor health practices. The new safe Surgery Saves Lives established a “WHO surgical checklist” as a working tool for surgical teams worldwide to ensure patient safety. This one page document which contains three main components: “Check in” (before induction of anaesthetic, “Time Out” (before skin incision) and “Sign Out” (before patient leaves theatre). The document is to reinforce the patient as central focus of care, improve team communication and lastly promotes positive patient safety culture. 

There are many different interpretations of the “time out” protocol. Most theatres tend to follow their own protocols. The recognised practice of “time out” is immediately prior to commencement of surgery. All surgical team members stop what they are doing to participate in the time out. The surgeon, anaesthetist and the scrub nurse should undertake a “time out” to verbally confirm the intended site, operation, side and identity of the patient checking this information against the patient’s identification bracelet, the operating list and the consent form/patient health records. The surgeon, anaesthetic and nurse can verbalise any patient-specific concerns I.e. anticipated blood loss, equipment issues or any concerns. Research confirms that wrong site surgery is rare, but it is tragic for the patient, surgeon and all other healthcare providers. 

The theatre is regarded as one of the more complex working healthcare environments. It consists of a very high level of technological equipment and a multiple disiplinary approach of personal, ranging from surgeons, anaesthetists, medical students, nurses and nursing students and theatre technicians. There is an associated high stress levels in performing in a high-risk situations and under a time restraint. The incidence of medical error in Ireland according to the Institute of medicine report is 500 – 550 of hospital deaths per year.

Surgical complications are common and often preventable. Some of the reasons believed to be the contributing causes to surgical errors are: poor preoperative planning, failure of the surgeon to exercise due care, lack of communication between the patient and the physician, misreading of patient’s results I.e. patient’s x-rays. Another preventable incident is where the patient’s specimen goes “missing”.  Where a patient goes through a surgical procedure in order to obtain a sample of the tumour/growth, in order to get a diagnosis and specimen has not gone to the Lab. In some hospitals the responsibility has been given to the scrub nurse to look after the specimen. This practice could be perceived unfairly that the medical team can not be trusted to ensure that such an important specimen would reach the lab.   


An analogy that tends to be used to compare safety in the operating theatre is the aviation cockpit of an aircraft. The responsibility of life and death situations that is left in the hands of the surgeon or be it the pilot is the common link. “Team work in the operating theatre lacks the formalisation of aviation cockpit crew” Grote et al (2004). That the Tenerife air crash accident of 1977 highlighted the undue stress that was put on the pilot compare to the stresses of a surgeon going to perform an operation. The one aspect that maybe considered is that the pilot must do their own checklist and are not reliant on their co-workers to take away his/her responsibilities. Health and safety is very much involved in the whole aspect of the aviation industry. For example the amount of flying time that is restricted to avoid potential accidents due to fatigue. Surgeons on the other hand have a restricted time in public hospitals but what about their private patient time? Another issue is the classic illegible handwriting situation that has a huge scope for misinterpretation leading to confusion and health risks. Where are the mandatory stipulations that any clinical document must be printed in legible handwriting?  

Both pilots and surgeons are very much dependant on “team work” and yet there is a problem with surgeons lack of “buy in” to the concept of “time out”. Like everything new it takes time to adjust to new ideas. And yet this “Time out” process is very much led by the nursing profession. It seems that initially it was perceived as a repetition of documentation. It has to be acknowledged that it was the nurses who took it on board and streamlined it to what it is now.  Implementing a patient safety solution needs a standard National policy and a checklist to encourage compliance and to avoid the ciaos of variance that leads to confusion. There should be a shared responsibility to ensure correct site surgery amongst nurses and medial staff. By reviewing and auditing the process together as a team it can reduce the barriers and encourage education and communication. Lastly this will make not only the patient’s safer but will reduce costs of litigation and pain.       






1 comment:

Mairin said...

Wonderful work Suzanne, well put together. The "TIME OUT" practise is vital in the theatre setting and where invasive procedures are being carried out. With all the 'rushing' and trying to beat the clock...with the "whose next?''call ". It is vital to call halt for 1 minute and forus fully on the job at hand and do the checks.
Though on the Safety level...do you think a "3 strikes and your OUT" policy might get peoples' minds a bit more focused on their work and responsibilities???