patient safety quality healthcare

I-PASS and SBAR Handoff Tools Have Proven Benefits

Communication failures continue to plague patient care. Experts weigh in on why nearly one-third of malpractice claims involve a communication failure, leading to significant patient harm

For nearly two decades, communication failures have been frequently attributed to harmful events in healthcare. Judging by a new report looking at malpractice claims, those problems aren't getting any better.

The report, published in January by CRICO Strategies, a division of The Risk Management Foundation of the Harvard Medical Institutions Inc., analyzed 23,000 medical malpractice claims filed between 2009 and 2013 in which patients suffered some degree of harm. Researchers found that more than 7,000 cases featured at least one kind of communication breakdown and 44% of those cases resulted in high severity patient injuries or death. Nearly 60% of communication failures involved two or more healthcare providers, and 55% involved a miscommunication with the patient.

Although communication errors are not solely to blame for patient harm, they often serve as the catalyst to subsequent missteps, says Dana Siegal, director of patient safety for CRICO Strategies in Boston.

"To be quite honest, an error is very rarely a single missed step or missed event, it's a matter of multiple missteps lining up," she says. "There is a miscommunication and someone doesn't recognize it and that leads to a decision not to do a test which leads to a misdiagnosis."

For many healthcare experts, these statistics merely add to the overwhelming evidence that miscommunication continues to plague healthcare. A recent Institute of Medicine (IOM) report entitled Improving Diagnosis in Healthcare highlighted communication as a key focus area for providers (see "IOM report highlights long-standing concerns surrounding diagnosis," in the December 2015 issue of Patient Safety Monitor Journal). More than 15 years ago, IOM's landmark To Err Is Human report identified communication failures as a contributing factor to patient harm.

"I'm disappointed that we continue to have the same problems," says Frank Federico, RPh, vice president of the Institute for Healthcare Improvement (IHI). "We've been working on trying to improve communication for some time. Communication is the currency of healthcare; that's how we exchange information. We have to be able to know we have good systems in place and that we have good mechanisms in place."

By digging deeper into why and how communication failures occur, healthcare organizations can refine their approach to information exchange. Patient Safety Monitor Journal spoke with four patient safety experts about why communication failures occur so often in healthcare and what hospitals can do to reduce miscommunication.

This is an excerpt from the April issue of Patient Safety Monitor. Subscribers can read the rest of the article here. Non-subscribers can find out more about the journal, its benefits, and how to subscribe by clicking here.

Department of Homeland Security Issues Ransomware Warning to Hospitals

In response to a series of ransomware attacks that crippled healthcare systems across the country, the Department of Homeland Security (DHS), the U.S. Computer Emergency Readiness Team (US-CERT), and the Canadian Cyber Incident Response Centre (CCIRC) released a warning on specific types of ransomware used in recent attacks. The warning is directed at all organizations that use networked computer systems, but specifically mentions healthcare facilities and hospitals.

Locky and Samas are the two types of ransomware named as being behind the recent spate of attacks.

Ransomware, a type of malware that encrypts files with a key that’s withheld for ransom, emerged as a significant threat to healthcare systems this year. Hollywood Presbyterian in Los Angeles was among the first to report a ransomware attack, followed soon after by incidents at other facilities in California, Kentucky, and Canada. MedStar in Baltimore is the most recent organization to weather a ransomware attack. Ransomware typically takes a hospital’s entire network offline and locks providers out of electronic health records and email. Ransomware can be difficult for an organization to recover from and some files may be permanently lost.

Networks infected by ransomware are also likely infected by other types of malware, the warning says. Malware linked to ransomware infections may copy and transmit financial information including bank account numbers or credit card numbers.

Healthcare organizations are advised to take steps to prevent ransomware attacks. US-CERT recommends that users:

  • Back up data on separate servers
  • Have a recovery plan for restoring data from backup servers
  • Ensure all software and devices are operating on the latest version
  • Disable macros from email attachments
  • Use application whitelisting to create a restricted list of applications and software that are permitted to run and update

Organizations are discouraged from paying the ransom. Payment of ransom does not obligate a hacker to release the encryption key and does not guarantee that any files will be released. Organizations are advised to contact the FBI’s Internet Crime Complaint Center if they discover ransomware or other evidence of hacking on their network.

Mercy Selects Datix Patient Safety and Risk Managment Solution

Mercy, the seventh largest Catholic health care system, has selected patient safety and risk management software from Datix to give a comprehensive view of incidents, complaints and claims across the organization. After a thorough evaluation, Datix was selected as a result of its ability to aggregate patient safety data in real time. Datix’s powerful dashboards and report writer will provide the Mercy leadership team and managers with the ability to access and drill down into data to allow faster decision making, further progressing the culture of patient safety throughout the organization.

Dr. Keith Starke, Mercy’s chief quality officer, said, “Mercy is passionate about patient safety and technology. We were named as a ‘Most Wired’ health care organization last year by the American Hospital Association and were one of the first organizations in the US to have a comprehensive, integrated electronic health record to provide real-time, paperless access to patient information. The introduction of Datix will further enhance our ability to promote a culture of patient safety across the organization.”

Mercy includes 45 acute care and specialty (heart, children’s orthopedic and rehab) hospitals, more than 700 physician practices and outpatient facilities, 40,000 co-workers and more than 2,000 Mercy Clinic physicians in Arkansas, Kansas, Missouri and Oklahoma. The health care system receives around 10,000,000 inpatient and outpatient visits annually.

Dr. Peter Brawer, Mercy’s vice president of quality, added, “Datix will make it much easier to record adverse and near miss events and incidents and enable analysis and meaningful reporting at all levels of the organization, including the leadership team. We will be able to look at trends, identify issues and risks, and rapidly address them to increase safety and prevent repetition. The highly configurable nature of Datix software gives Mercy a tool to accurately reflect its current and future patient safety culture and processes.”

Datix brings transparency to patient safety data and its position as a leading global player includes large scale deployments in the US and Canada, 80% of the National Health Service in the United Kingdom and installations in other European countries, Australia and the Middle East.

John Scott, SVP Sales, Datix concluded, “We recognize the importance of data and analytics to Mercy as an organization. Datix is a proven patient safety and risk management solution with a long track record of helping healthcare managers make fast and effective decisions based on data and shared learning to help keep patients safe from harm.”


AORN Guideline Updates Focus on Counting, Communication to Prevent RSIs

Using a new evidence review model, AORN highlights key safety concerns, while one expert calls for more emphasis on human error.

Using a new evidence review model, updated guidelines released by one of the nation's leading surgical associations underscore the importance of clear communication and strong counting procedures to prevent the occurrence of retained surgical items (RSI).

The Association of periOperative Registered Nurses (AORN) released updates to its Guideline for Prevention of Retained Surgical Items effective January 15, 2016. The updated guidelines take the place of previous recommendations released in 2012.

Hospitals continue to struggle with RSIs. In January, The Joint Commission released a "Quick Safety" report building on its 2013 Sentinel Event Alert on unintended retained foreign objects (URFO). The Joint Commission reported that URFOs accounted for 115 of the sentinel events reported in 2015 and 112 in 2014, up from 102 in 2013.

Read more...

Safety Issues Dominate Joint Commission List of Most-Cited Standards of 2015

The Joint Commission’s latest list of most-cited standards was dominated by safety issues. Following a multi-year trend, eight of the top 10 cited standards came from the Environment of Care, Life Safety or Infection Control chapters, with most of them merely swapping places within the top 10.

The standards are those most frequently found not compliant by surveyors. Percentages indicate the number of organizations that were given Requirements for Improvement for the standards.

The top 10 most-cited standards of 2015 are as follows, based on 1,447 hospital surveys:

  • EC.02.06.01 (maintenance of a safe environment), 62%
  • IC.02.02.01 (reduction of infection risk from equipment, devices, and supplies), 59%
  • EC.02.05.01 (management of utility system risks), 58%
  • LS.02.01.20 (maintenance of egress integrity), 51%
  • LS.02.01.30 (building features provided and maintained to protect from fire and smoke hazards), 50%
  • RC.01.01.01 (maintenance of accurate, complete medical records for all patients), 47%
  • LS.02.01.35 (fire extinguishment features provided and maintained), 46%
  • LS.02.01.10 (minimization of fire, smoke, and heat damage via building and fire protection features), 45%
  • PC.02.01.03 (lawful provision of care, services, and treatment), 40%
  • EC.02.02.01 (management of hazardous materials and waste risks), 39%

For more information, visit here or see the April issues of Joint Commission Perspectives

Readmissions Dip 47% When Some Patients Self-Administer IV Antibiotics



By: Alexandra Wilson Pecci, HealthLeaders Media

Uninsured patients requiring prolonged courses of treatment with intravenous antibiotics can be trained to treat themselves at home and achieve outcomes comparable to patients who receive treatment in traditional settings, data shows.

Teaching uninsured patients how to self-administer IV antibiotics for outpatient parenteral antimicrobial therapy (OPAT) has paid off for Parkland Hospital, a safety-net hospital serving Dallas County, Texas.

The program has resulted in similar or better clinical outcomes than healthcare provider-administered OPAT and 47% lower 30-day readmission rates over a four-year period, according to a recent study published by PLOS.

Lead study author Kavita Bhavan, MD, medical director of the Infectious Diseases OPAT Clinic at Parkland, and assistant professor of internal medicine at the University of Texas Southwestern Medical Center, explains the program, in an interview with HealthLeaders. This is the first of two parts. The transcript of her remarks has been lightly edited.

About the program:
The program is for uninsured patients to self-administer antibiotics at home as an alternative to remaining in the hospital or a traditional healthcare setting to complete their therapy. Patients who receive OPAT services are typically those who have been diagnosed in the hospital with an infection that requires a prolonged course of antibiotics.

This is done for more invasive infections, whether it’s osteomyelitis (an infection of the bone) or endocarditis, a heart valve infection, for example.

OPAT has been around since the late 1970s, was initially shown to work in pediatric populations, and then in adult populations. We started this program in 2009. I’m proud to say that Parkland is the first to publish outcomes of doing this kind of model. We don’t know who else is doing something similar to this.

On why Parkland started the program:

We started the OPAT program because we recognized that patients with infections who require long-term antibiotics typically receive concentrated diagnostics and therapeutic services.

The first couple of days is when we’re really busy trying to figure out what’s wrong with the [patients], trying to figure out a diagnosis, getting a treatment plan going—there’s a lot of stuff happening. But once they’re stable—simply because they have no other place to go—safety-net hospitals would simply just absorb that and have them stay in the hospital or discharge them to another setting to receive care, but not home, necessarily.

We talk about healthcare disparities in this country, and see that the patients who are insured have the option to be discharged early to home or to a lower-cost nursing facility to complete their therapy. But unfunded patients don’t typically receive these options and they usually remain in the hospital.

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Exploring the Intersection of Concurrent Surgeries and False Claims Enforcement

Renewed focus on concurrent surgeries underscores patient safety concerns. Newspaper investigation has thrust issue into national spotlight, prompting American College of Surgeon Updates

The practice of concurrent surgeries has become a top concern for hospitals across the country following a Boston Globe investigation into the practices of a reputable Massachusetts hospital.

In October, the Globe published a lengthy exposé into the practice of "concurrent" or "double-booking" surgeries at Massachusetts General Hospital (MGH), ranked as the top hospital in the nation by U.S. News and World Report in 2015-2016. The Globe's investigation revealed an ongoing battle within the health system that pitted one long-time surgeon against the hospital's top brass in his quest to eliminate concurrent surgeries. The investigation also described specific incidents in which patients were harmed or even paralyzed during double-booked procedures.

The Globe investigation has pushed the issues of concurrent surgeries - a common practice among many academic medical systems across the country - to the surface, drawing criticisms from patient safety advocates and prompting organizations like the American College of Surgeons (ACS) to review current policies on concurrent or overlapping surgeries.

Read more...

EHR Copy and Paste Best Practices Toolkit Released

Copying and pasting information in EHRs is a common practice that can save busy physicians and other staff valuable time, but it can also introduce significant errors into the record. In an effort to help physicians make the most of the copy and paste function while protecting the integrity of the record, the Partnership for Health IT Patient Safety released a toolkit for the safe use of copy and paste in February 2016.

The toolkit offers four safe practice recommendations for using copy and paste in EHRs:

  • Recommendation A: Make copy and paste material easily identifiable
  • Recommendation B: Ensure the provenance of copy and paste material is easily available
  • Recommendation C: Train and educate staff on the appropriate and safe use of copy and paste
  • Recommendation D: Monitor, measure, and assess copy and paste practices

Each recommended measure is broken down in a chart, detailing what issue the measure addresses, potential actions that can be taken, the target audience (vendor or provider), and possible solutions. Recommendation A, for example, addresses the concern that an EHR might not differentiate between information that was entered directly into a specific record and information that was copied. Some of the potential solutions the toolkit offers are making copy and pasted text appear in a different font or color or otherwise distinct and easily flagged for review. These solutions would require action on the part of both vendors and healthcare providers and the toolkit acknowledges that solutions that involve changes to technology can’t be implemented immediately.

Other recommended measures, such as education and training, can be addressed by individual healthcare providers. The toolkit suggests providers offer regular hands-on training, demonstrate the correct way to use any new technology, and offer regular feedback to staff.

New 2017 National Patient Safety Goal Focuses on CAUTI Prevention

The Joint Commission today announced plans for a new National Patient Safety Goal (NPSG) aimed at reducing catheter-associated urinary tract infections (CAUTI). The prepublication standards for the NPSG are online and cover standards for accredited hospitals, critical access hospitals, and nursing care centers. The NPSG is intended to align CAUTI treatment and prevention with the updated Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014.

The NPSG goes into effect on January 1, 2017.

Source: Accreditation & Quality Advisor.

FDA Proposes Ban on Most Powdered Surgical Gloves

On Monday, the U.S. Food and Drug Administration (FDA) proposed banning most powdered gloves in the U.S. While the use of these gloves is on the decline, the risks associated with them for both healthcare workers and patients, cannot be corrected through new or updated labeling, says the FDA.

“This ban is about protecting patients and healthcare professionals from a danger they might not even be aware of,” says Jeffrey Shuren, M.D., director of FDA’s Center for Devices and Radiological Health. “We take bans very seriously and only take this action when we feel it’s necessary to protect the public health.”

The powder that is sometimes added to natural rubber latex gloves to aid in putting them on or taking them off, can carry proteins that might cause respiratory allergic reactions. Also, while powdered synthetic gloves don’t typically cause allergic reactions, they have been linked to potentially serious side effects such as severe airway inflammation, wound inflammation, and post-surgical adhesions. It’s important to note here that these side effects have been associated with powder used in gloves, regardless of the type of the glove used.

The ban would apply to powdered surgeon’s gloves, powdered patient examination gloves, and absorbable powder for lubricating a surgeon’s gloves. It does not extend to non-powdered surgeon and examination gloves. Those gloves will remain listed as Class I medical devices, which are devices that pose the least amount of risk to the patient or healthcare worker.

The public will be able to comment on the proposed rule online at for 90 days.

New York Moves to Electronic-Only Prescriptions

Next week, New York will become the first state to require all prescriptions be written electronically. Physicians who fail to comply will be penalized with fines and/or imprisonment. This is the second part of a 2012 state law, I-Stop, which was designed to help fight prescription opioid abuse.

The first part of I-Stop went into effect in 2013 and is an online drug registry that contains all of the controlled medications prescribed to a patient. Physicians need to consult the registry before prescribing medications, according to a recent article in the New York Times.

Minnesota has a similar law, however, physicians aren’t penalized for using paper prescriptions.


AHIMA Seeks Public Support for National Patient ID

By John Commins, HealthLeaders Media

Advocates for a voluntary patient safety identifier envision a process that would allow patients to create a way for medical systems to recognize them quickly and accurately, in much the same way as financial sector businesses.

A leading trade group for the nation’s health information technology sector is asking patients to endorse the creation of a national voluntary patient safety identifier.

The American Health Information Management Association said Monday that it has launched a petition and wants to send the Obama administration at least 100,000 signatures from patients who support the idea.

The petition, which AHIMA hopes to send to the White House by April 19, asks for the removal of a ban that prohibits the Department of Health and Human Services from participating in efforts to create a patient safety identification system.

“That was way back in the original draft language of HIPAA. It had language specific to unique patient identifiers,” says AHIMA’s Pamela Lane, vice president, policy & government relations. “Back in the day there was a lot of concern about big government spying on people. So, when the final language came out, they’d taken the references to patient identifiers out.”

“To keep it from getting added back in, there was language put into the appropriations bill in 1999 that said that HHS could not use any of their resources on patient identifiers. They can talk about the problem, but they can’t talk about the solutions,” Lane says.

2,488 Maria Garcias

Lane says the need for patient safety identifiers continues to grow as 80% of doctors and 97% of hospitals use electronic health records. She cited a study conducted by the Harris County Hospital District in Houston, TX, which found that, among 3.5 million patients, there were nearly 70,000 instances where two or more patients shared the same last name, first name, and date of birth. Among these were 2,488 different patients named Maria Garcia and 231 of those shared the same birth date.

A specific patient identifier would ensure that each patient’s health information is kept together and is complete and remains under the patient’s control. AHIMA and other supporters of the voluntary patient safety identifier envision a process that would allow patients to create a way for medical systems to recognize them quickly and accurately, in much the same way as financial sector businesses.

“We don’t know what it will look like. We are not proposing any particular technical solution, but we don’t believe the technology is the problem anymore,” Lane says. “It could be something as simple as an email address specifically for healthcare, or could be like a banking [or] ATM number. The technology exists for there to be lots of things to talk about. There are brilliant minds that have been working now for almost 20 years since HIPAA was enacted on technical solutions. We just want to be able to have private/public conversations.”

Lane says AHIMA members often see firsthand the problems associated with mismatching patient IDs.

“We’ve waded into it because we are the profession in healthcare that has to clean up a lot of the problems,” she says. “Let’s say there are two patients with the same name. Many, many times the people who match those records and validate those identities are EMR professionals. We are the ones who have the closest real-world knowledge of the problem.”

The petition marks the first direct appeal to patients and consumers by AHIMA, which is not well known outside of healthcare circles. “We have not traditionally been consumer-facing as an association. This is a brand new avenue of advocacy for us,” Lane says.

“This is a great opportunity to say ‘I am the one who on the back end fixes the problem and I am going to help you find ways to fix it on the front end.’ We also have worked with other associations and groups, as they reach out to their members, who reach out to patients. It’s a heavy lift, but we don’t have to do it all ourselves.”

Source: HealthLeaders Media


Hopkins: 'Cascading Accountability' Boosts Ambulatory Quality, Safety

By Alexandra Wilson Pecci, HealthLeaders Media

Johns Hopkins Medicine coordinates high-quality care across ambulatory care centers, using a model it says has resulted in improved metrics associated with breast cancer screenings, immunizations, and diabetes management.

Johns Hopkins Medicine's commitment to quality care is evidenced by a governance, oversight, and accountability model that is cascading throughout its ambulatory medicine sites.

"Hopkins has always had an emphasis on quality and safety that was really borne from our inpatient experiences," says Steven Kravet, MD, president of Baltimore, MD-based Johns Hopkins Community Physicians.

Yet how to ensure that the quality of care remains high, even as the organization grows, and in particular, grows on the ambulatory side? Like many health systems and hospital operators, JHM is seeing more growth in its ambulatory services than its inpatient services. And outpatient services are being distributed not only throughout the community, but beyond it.

In the wake of rapid outpatient growth, JHM recognized the need for better ambulatory quality and safety processes to maintain the high-level of care that's become the inpatient standard. So it developed a model to coordinate high-quality care across its ambulatory care centers, which resulted in improvements in metrics pertaining to breast cancer screenings, childhood immunizations, diabetes management, and prenatal care.

Kravet is lead author of a paper in the March issue of Academic Medicine that outlines the JHM model's structure and success.

JHM has two hospital outpatient centers and more than 39 primary and specialty care outpatient sites where nearly two million non-ancillary ambulatory visits are conducted annually across the health system, the paper notes. Often, each ambulatory care practice has its own organizational structure.

To ensure consistent quality, JHM created a governance, oversight, and accountability model that cascades throughout the ambulatory sites. It consists of:

An Ambulatory Leadership Dyad
The dyad consists of a senior physician leader in the role of ambulatory chief quality officer (CQO) and a masters-trained nurse in the role of a senior director for ambulatory quality. The CQO was selected from the Office of Johns Hopkins Physicians (OJHP), which coordinates and oversees ambulatory physicians and staff. CQO dyad organizes and oversees analytics and dashboards for the quality metrics.

The Ambulatory Quality Council
The AQC comprises key leaders from each ambulatory practice setting, the OJHP, and JHM's Armstrong Institute for Patient Safety and Quality. Some of the practices are represented by a physician and an administrative leader, while others are represented by a physician, an administrative leader, and a senior nurse.

"It's created a table to hear what's going on in ambulatory, even when it's distributed throughout the community," Kravet says.

The AQC is also divided into four workgroups which share best practices, and each workgroup is devoted to a different theme:

  • Performance measures
  • Value
  • Patient safety/risk
  • Patient care/experience

This "cascading accountability model… provided a quality structure for all JHM ambulatory practices. As part of this model, the JHM Quality Board Committee created a quality and safety accountability system, establishing goals and measures for the CQO dyad. The Ambulatory Quality Council then defined its goals, set standards, monitored performance, and reported to the JHM Quality Board," the paper says.

Kravet says this approach brings people together to create an accountability model, set standards, facilitate processes, and distribute knowledge in a practical way. In a way, it's reminiscent of how franchises operate: Each is an independently owned business, but must adhere to the model and standards of the overall organization.

"The same measures… are then pushed down to the unit level," Kravet says. "We distribute the dashboards and the expectations."

In addition, the paper says that "if an ambulatory practice continues to report substandard performance metrics, its leaders as well as the ambulatory practice chief quality officer are required to create an action plan and present it to the Board of Trustees."

Since it was implemented in early 2014, the model has resulted in improvements in a dozen government-required performance metrics. "An additional benefit was an improvement in Medicaid value-based purchasing metrics, which are linked to several million dollars of revenue," the paper says.

"It has created a great sense of accountability," Kravet says. It's broken down silos by putting patients at the center of care and encouraged stakeholders to have a voice in shaping and sharing goals. 

Moreover, the model is scalable, and the authors believe it can be expanded to "other ambulatory practices within and outside JHM, including to regional and international partners," the paper reports.

"Patient safety is something that everyone can galvanize around," Kravet says. "When people are part of the design, they have greater buy-in into the accountability."

Alexandra Wilson Pecci is an editor for HealthLeaders Media.

Failure Recovery Tool Offers Guidance Amid the 'Chaos and Shock' of Medical Errors


This article appears in the March issue of Patient Safety Monitor.

Hospitals need to have a structure in place to respond to patient safety failures

Healthcare can be a stressful industry to work in, particularly when something goes wrong. Instead of relying on humans to react under pressure, one organization is offering a structured approach to patient safety failures.

In January, LifeWings Partners LLC, an organization that specializes in patient safety training and best practices, released a failure recovery tool aimed at standardizing the way hospitals respond to medical errors. Patient Safety Monitor Journal spoke with Stephen W. Harden, chairman and CEO of LifeWings in Collierville, Tennessee, about the new tool and how hospitals can integrate it into their patient safety systems.


Editor's note: The following has been edited for space and clarity.

Q: Can you tell me why you decided to focus on failure recovery?

A: Despite their best efforts, there is a lack of perfection on the part of healthcare. Healthcare is provided by humans and one thing we know about humans is they are going to make mistakes. So it's not perfect and the mortality statistics point that out.


Q: Why do clinicians deviate from protocols?

A: There are basically four reasons why a protocol isn't followed:

One reason is people don't know the protocol exists because they've never been taught it. That's a training problem.

Some people have been taught that there's a protocol, but they don't actually know how to follow it. Teaching means that you've told them how to do it and explained the importance of the how and the why. Then you have an expert demo how to do it. Then the learner practices it under the watchful eye of the expert?they actually try and do the protocol. And then the learner gets feedback from the expert.

The third reason healthcare professionals don't follow protocol is they can't. There is some sort of barrier the organization has left in the way. Maybe the protocol is written down, but the manual is hidden away in someone's office. So you've added too many steps to the healthcare provider's workday to go get the protocol and follow it. More commonly the reason they can't is they are physiologically not capable of following it. What that means is you've mis-hired somebody. You've hired someone that can't adequately do the job.

The fourth reason is they are making a conscious decision not to. Typically, that's because they think their way is better or that it's not really required. If you think your way is better, or you feel like you can combine some steps to make the protocol more efficient. Or you don't have time to do it that way and you've developed a shortcut. There are all sorts of logical reasons on the part of the provider where they think, "I really don't have to go through all these steps?there's a quicker, smarter, easier way to do this."

Quite frankly, that is really the main reason protocols are not followed, and the problem that managers and supervisors within healthcare struggle with the most is willful noncompliance.


Q: How does the checklist help with that? How does it identify which of these reasons led to failure and help resolve willful noncompliance?

A: I'm not sure it helps any of those reasons. What it does do is it acknowledges the fact that humans do make mistakes despite their best efforts. In that moment?when you realize you've made a mistake and you need to recover from it?you really do need a blueprint or a checklist to follow, when maybe you're not cooking on all cylinders. When a mistake has been made and you've hurt someone you didn't intend to hurt, everyone is in a state of mini shock. You need a guideline to follow to help plot your steps forward in the midst of the chaos and the shock. And that's what it's for.

The analogy for this is a flight crew on a commercial airline 30,000 feet above the ocean and three hours from nearest landfall, and they have an engine fire. Well, that's going to create a lot of shock and consternation in the cockpit; I don't care how experienced the crew is. You don't want them to try and use all their cognitive abilities to come up with how they are going to respond to an engine fire 600 miles from nearest landfall with 235 people on board. You want those steps laid out for them so, in the midst of this mind-numbing shock, they don't have to depend on their cognitive abilities when under so much stress.

It's the same sort of analogy. You hurt a patient who put their life in your hands. Your job was to fix them and now you've hurt them. There's a lot of stress. We're not at the top of our game cognitively. Having a checklist to follow that guides you through these steps in the midst of that performance detriment is really valuable.


Q: Is that why hospitals struggle? Because they don't have that structure in place?

A: I don't know. I can say they don't have recovery protocols in place, but it's probably not as well-defined as a protocol to deal with a bloodstream infection or a protocol to deal with ventilator associated pneumonia.

What we're trying to do is give high-performing teams in hospitals a checklist to follow to guide them through that high stress high workload moment after they realize they've hurt a patient.


Q: You've listed nine steps in the failure recovery tool. Are any of those particularly important or ones that hospitals tend to neglect?

A: If you pinned me down and made me pick one, I would say most hospitals struggle with acknowledging throughout the team that something was amiss and confronting it head on. There's a culture of silence, both because no one wants to admit a mistake, number one, and number two, they don't want to get sued.

This is less so now in my career helping hospitals than it was 10 years ago. Ten years ago, I was always shocked at the culture of silence that pervaded around a mistake. That's one of the primary ways we learn?acknowledging something you didn't want to happen happened, understanding why it happened, and disseminating the learning. That's an area of healthcare that's way, way behind aviation. Aviation is really good at picking at its scabs and figuring out why that happened, sharing lessons learned, and letting others learn from your misfortunes so they don't repeat the mistake. Healthcare is not there yet.


Q: But you feel that has shifted over the last decade?

A: I do believe there is a groundswell or shift happening slowly but surely. But they certainly aren't where aviation is in terms of publicizing and acknowledging their mistakes so everyone can learn from them in a nonpunitive environment.


Q: How would you like to see hospitals use this tool?

A: Here's what I want them to do: I want them to say, "Yes we need something like this. This is a good start. Let's blow this up and build it for our specific purposes."

I'd like to see them use the underlying principles and customize it to their needs. Quite frankly, that's the only way anyone is going to use it. The one thing we've discovered about all the protocols we promote and offer to all of our client hospitals is they have to take those and blow them up and rebuild that in their own vision and culture and their own way.

If you build something yourself and it fits your people and culture and your particular medical society, you're way more likely to use it than if someone just handed it to you and said, "Here, use this."

This article appears in the March issue of Patient Safety Monitor Journal.

Patient Safety Awareness Week is Underway



Patient Safety Awareness Week (March 13-19) presented by the National Patient Safety Foundation’s (NPSF) United for Patient Safety Campaign is underway. Healthcare facilities and leading patient safety organizations across the country are expected to participate in patient safety week.

The United for Patient Safety Campaign, announced by the NPSF last month, encourages dialogue between patients and healthcare providers to promote safety  for both patients and healthcare workers. Participants are encouraged to download educational materials, post pictures, and share their plans for Patient Safety Awareness Week.

NPSF is offering two major events this week, first up is  a Twitter chat – “Patient Safety in All Settings” that will take place at 2 pm EST on March 15th. The chat will focus on safety issues across all healthcare settings.  Participants can join the chat by using the hashtag #PSAW16chat.

On Thursday, March 17 at 1 pm EST, the NPSF is hosting a free webcast, “Patient Safety is a Public Health Issue.” Leading experts from the Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare and Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC), and NPSF will discuss how patient safety is being addressed at the national level.

As part of Patient Safety Awareness Week, The Joint Commission unveiled a new web page today, dedicated to patient safety resources, including a new issue of its Quick Safety newsletter about the Patient Safety Systems chapter of the hospital manual.

We would like to know your plans for Patient Safety Awareness Week. Email me at This email address is being protected from spambots. You need JavaScript enabled to view it. and we’ll share your plans with your colleagues throughout the week.




ABQAURP American Society for Quality American Society for Quality Healthcare Division Consumers Advancing Patient Safety
EMPSF Institute for Safe Medical Practices
Medically Induced Trauma Support Services (MITSS) Medication Safety Officers Society NPSF Partnership for Patient Safety Society to Improve Diagnosis in Medicine