There is value in the prospective review of hazards. An approach to improve healthcare safety is to review hazards and assess proposed solutions using the framework presented below. This process could complement established incident reporting systems.
Hazard – There is value in the prospective review of hazards over the retrospective assessment of incidents and near misses. Staff may be more willing to present hazards knowing that no one is to ‘blame’. The solutions provided may be forward looking avoiding the ‘retrospectoscope’, and less likely to lead to name/blame/train/shame approach. The proposed solution should be intuitive, evidence based, and cost conscious – in that order.
1.1 Intuitive – Definition: using or based on what one feels to be true even without conscious reasoning; instinctive. Many safety solutions are intuitive, they make sense, even though they have not been subjected to the rigors of strong trials.
For example we all intuitively know that it is better to hold a 4 year old child’s hand while they cross the street to reduce the risk of them being run over. We are unlikely to request evidence to support this.
1.2 Evidence Based – Is there sufficient/strong evidence to refute the intuitive solution?
At the same time if there is evidence to support the intuitive solution then it would be useful to provide/collect it.
Note that most people and groups are comfortable with the status quo. Changing a piece of equipment or process upsets this. Evidence Based Practice may occasionally be used inappropriately to hinder a proposed solution. For example if someone was against the practice of holding hands they could ask ‘show me the evidence that holding a childs hand while crossing the road is safer’. It would be difficult, prolonged, and potentially impossible for us to provide convincing evidence primarily because adverse events are rare. (See hazard triangle)
1.3 Cost conscious – As healthcare evolves safer innovations will be developed. Unfortunately these innovations often cost more than the equipment or processes they are designed to replace. The healthcare dollar is limited and occasionally the increased level of safety they may provide cannot be afforded.
A good example would be the provision of anaesthetic services for endoscopy lists. While providing an anaesthetist for every endoscopy list would deliver optimal safety there are insufficient resources to allow this. In turn we have ANZCA minimum safety standards for sedation and provide our non-anaesthetic colleagues with sedation training and anaesthetic run endoscopy lists for sicker patients.
We may discover that we save money through optimal management avoiding costly patient morbidity.
2. Decrease or same workload on the front line – Front line staff often work in complex environments. It is important that proposed solutions do not increase the burden of work.
Traditional approaches to overcoming error have focused on policy writing. (See Hierarchy of Intervention Effectiveness) Another policy will likely only increase staff accountability without improving safety. If education and policies are the only perceived solution they need to be centralised and easily accessible. Avoid creating yet another form to go with the sea of forms that exist in hospitals.
3. Does not introduce its own set of problems – It is important not to replace one hazard with another that may be even worse. Consider all of the problems the proposed solution may present.
4. Goes to source of problem – Often what is really required to remove a hazard may seem out of reach to front line staff and so may not be proposed as a solution. We must be prepared to approach those who create the equipment and systems we work with.
5. Survey front line staff opinions about proposed solution – Proposed solutions will be better adopted if they receive the blessing of front line staff working with them. Open communication with the front line throughout the adoption of the ‘hazard feedback framework’ is paramount. A good question to ask the front line staff is ‘how will this proposed solution fail?’.
6. Trial solution – Where possible solutions should be trialed prior to their adoption. The increased availability of simulation centres may provide an appropriate environment.
7. Implementation, follow up, further feedback and survey – Ensure all appropriate and affected groups have provided their agreement for the solution prior to its implementation. Maintain open lines of communication so staff may provide concerns or feedback about the solution. Survey affected staff regarding their beliefs about the solution. Note any ‘work arounds’ which indicate inefficiency with the proposed solution. Provide formal feedback to the hazard reporter and maintain transparency throughout so staff can observe progress.
8. Presentation and transparency – Present the solution to other patient safety groups, hospitals etc. Formally present response to managing hazard whether successful or not along with lessons learned along the way.
We have applied this framework reasoning to several of the safety hazards we are attempting to resolve. The example below illustrates how the ‘hazard feedback framework’ could be adopted:
Hazard – Indistinct Pourable Chlorhexidine Antiseptic. Almost colourless solution potentially leads to it being mistaken for normal saline and injected into epidural space and other sites.
Suggested Solution – More distinct coloured solution. Perhaps develop a colour standard i.e. only solutions that are sufficiently distinct will be available.
1.1 Intuitive – More distinct colouring will be less likely confused with normal saline so less likely to be injected in to a central line or neuraxial space.
1.2 Evidence Based – No evidence to refute this.
1.3 Cost Conscious – The cost of removing this hazard would lie with the manufacturer.
2. Decrease or same workload on the front line – Same workload
3. Does not introduce its own set of problems – One concern is more vividly coloured solutions stain the skin, stains being difficult to remove, stain may mask pallor due to poor skin perfusion e.g. post op foot surgery. Perrigo (manufacturer) have designed a colour that is obvious, but does not stain skin.
4. Goes to source of problem – Approached Perrigo to develop alternative more vividly coloured solution (they are in the process of doing this). Approached TGA to ban Riotane tinted pink (unsuccessful). Consider further letter to TGA requesting a standard minimum colour for chlorhexidine and alcohol solutions.
5. Survey front line staff their opinions about proposed solution – More vividly coloured solutions are already being used in many hospitals without apparent problem.
6. Trial solution – More vividly coloured solutions are already being used in many hospitals without apparent problem.
7. Implementation, follow up, further feedback – Awaiting Perrigo to provide new coloured solution.
8. Presentation and transparency – The approach we have taken is published on our website and is continuously updated as progress is made. (see here)
We would be delighted with your support and believe the ‘Hazard Feedback Framework’ will be a catalyst for a greater patient safety culture.
Proposed Solutions In Summary:
1.1 Intuitive – based on what one feels to be true even without conscious reasoning.
1.2 Evidence Based – Is there sufficient evidence to refute this intuitive solution?
1.3 Cost Conscious – occasionally the increased safety a solution offers can’t be afforded.
2. Decrease or same workload on the front line
3. Does not introduce its own set of problems
4. Goes to source of problem – approach equipment or system manufacturers.
5. Survey front line staff – ‘How will the solution fail?’
6. Trial solution – consider using simulation centres.
7. Implementation, follow up, further feedback – ensure agreement and transparency.
8. Presentation and transparency – present to other patient safety groups.