Chief Nurse: How to Reduce Serious Safety Events

HealthLeaders: What are the most common patient safety issues in hospitals and health systems?
Lanie Ward: The most common patient safety issues that I see through my eyes as a CNO are [these] three: medication errors, hospital-acquired infections, and patient falls. There’s no question that med errors happen with the greatest frequency. Many of them cause no harm to the patient, but some do cause severe harm and even result in patient death. That’s why it’s so important that we carefully evaluate all med errors, even if there was no harm.

At CHA, we put much focus on two hospital-acquired infections—catheter-associated urinary tract infections and central line-associated bloodstream infections. The frequency of these infections is much less than med errors, but they are harmful to our patients. And I must tell you that my infectious disease experts would really be upset with me if I didn’t mention handwashing. That’s the No. 1 one thing to prevent spreading infections patient to patient.

Patient falls are a big safety issue, and these occur everywhere, from our ambulatory clinics to our emergency departments, to our med surg-units, and even in our ICUs because some patients are more prone to falls than others.

We do find in our hospitals that patients are most at risk for falling when they’re toileting—going into the bathroom, while in the bathroom, and returning to the bed—so that’s why the use of purposeful rounds is so important. Purposeful rounds are proactive, frequent rounding and in those rounds we would toilet the patient.

And even though many disciplines play an important role in eliminating or reducing these patient safety issues, there’s no question that nursing plays an enormous role because they’re there all the time.
HL: What is one of the most effective quality improvement initiatives you’ve been part of to reduce serious safety events?

Ward: I feel fortunate to have been part of a health system that embarked on the journey of becoming a high-reliability organization. In my career, I found that this journey was the most transformational of any I’ve been involved with, and it resulted in a sharp reduction in our serious safety events. Now that I’m working at CHA, we are embarking on that same journey of becoming a high-reliability organization.

I will start by saying that the underpinning of a high-reliability organization is that there has to be a total commitment by leadership to the goal of zero harm. They have to commit to this journey financially, from a time standpoint, and to support all the staff.

Everyone in our organization received training on the principles of safety and the steps that we were going to take and the expectations of them. We took a lot of our principles from other industries—aviation and nuclear power—because those industries have been much more successful than healthcare in those areas.

There were a lot of steps in that whole journey, but the three that I thought had the most impact on reducing our serious safety events were:

1. The implementation of safety huddles

2. The expectation of speaking up for safety

3. The implementation of a just culture.

Daily safety huddles focused on patient safety issues, concerns, resolution, and follow-up, and they were implemented not only at the hospital level each day but also at the department level. In these huddles we even spoke using safety language and clarifying language so that we had the skills we need for verbal orders for handoffs, and other times that clarification was needed with communication.

Have you heard of the NATO phonetic alphabet [Alfa, Bravo, Charlie, etc.]? I would say at the huddle, “This is Lanie Ward; that’s Lima Whiskey for the L and the W, and today we have 15 patients—that’s one-five patients—who have indwelling Foley catheters.” I found that using that language every day, and multiple times, kept the focus on all of us knowing we’re doing something different. We’re working on patient safety, and to be honest, it was a lot of fun. That, and the daily huddles helped us focus on patient safety at all levels.

The second was the expectation of everyone speaking up and being able to, quote “stop the line [meaning to stop a procedure in its tracks].” All of us were taught how to speak up and how to escalate it, and also how we were to respond appropriately if we were on the receiving end of someone speaking up. This training eliminated the power distance or the hierarchy between a nurse and a doctor or between a housekeeper and a nurse.

Just to give you an example of how that went, with using aviation language, a housekeeper might see a doctor walking into a room and not wash his hands. The housekeeper was expected to say, “Don’t forget to wash up,”—a soft speaking up—and the physician was expected to say, “Thanks for the cross check,” not “Who are you telling me to wash my hands?”
If the physician didn’t respond in the way he or she was expected to, our staff were taught how to escalate and say, “For patient safety, it’s important we wash our hands.” If he still ignored me, then the key word was “concerned.” Anyone in our organization could say, “I have a concern,” and that phrase was supposed to stop the line. It really did help stop the power distance and make people feel comfortable. And they were obligated because that was our expectation.

Third, we implemented a “just culture.” In the past, healthcare has held individuals accountable for all errors, and in a just culture, people are not held accountable for system failures. We had an algorithm developed that would help leaders and staff understand why a particular error occurred.

An example would be: Was the medication barcode scanning device not available, or did the nurse choose not to use it? And [that would help determine] whether it was a system problem or if we need to hold our staff accountable.

One of the things that I learned along that journey was what I call “measuring in abundance,” where … I would have nurses report how many days their unit was fall-free, not how many falls they did have. It’s more of a positive thing.

HL: What should nurse leaders do to help improve their organization’s culture of patient safety?
Ward: It’s my responsibility and all nurse leaders’ responsibility to make it as easy as possible for nurses to practice safely and make it hard for them to make an error, and we need to do that by doing things like making sure we provide them with the most up-to-date modern technology; that good processes and systems are in place; that staffing is where it should be; and that their environments are conducive to safety.

Second, nurse leaders need to listen to and use the voices of the nurses who are patient-facing. We are often sitting in offices, so we need to listen.

Third, each unit should prioritize not 10 patient safety goals, but two or three based on the specifics of their unit and then identify and implement the best practices to help meet those goals.

Fourth, I talked about measuring in abundance while still looking at each incident of a fall to understand why it happened. Nurse leaders should measure abundance and celebrate, celebrate, celebrate the successes. It is so motivational for staff.

Number five, I’m a very firm believer in learning from near misses and errors that cause no harm. Don’t ignore those because they could have easily gone the other way.

Finally, always remember that ‘to err is human,’ and support your staff. They need our support.