What you see depends on what you’re conditioned to see:
We’ve grown up in healthcare seeing education, policy writing and checklists as the most powerful tools for improvement.
Those in the most influential positions are often academically gifted and tend to reinforce this behaviour. Education has served them proud, it has enabled them to excel. They may believe if others are as well educated many of the issues will be resolved.
Resultantly in the top down structures of healthcare education and policy writing is where the energy is invested.
Unfortunately human factors engineering teaches us that these people focussed interventions are relatively ineffective when it comes to improving safety.
While education and training are important, if healthcare safety is to improve we need a paradigm shift cultivating system focussed interventions. The aviation industry underwent this paradigm shift many years ago leading to massive improvements in safety.
Forcing functions, at the top of the hierarchy, prevent staff from committing the error – in effect designing the error out.
Patient Safe have focussed on several hazards and are striving to implement the forcing functions to prevent them. See:
– Central lines which open to air
– APL valves which trap open
– Indistinct pourable chlorhexidine
– Valveless intravenous fluid bags
Our hospitals are teaming with thousands of hazards. Used in the correct way they won’t cause a problem – however they’re not designed to take into account the human in the room. Despite teaching and policies they continue to be used incorrectly and patients suffer as a result.
We’ve focused on a few to help highlight the problem. The longer these hazards remain in place the more obvious it is healthcare safety desperately needs this paradigm shift.
Change won’t happen overnight – perhaps it will occur through tens of thousands of steps.
All healthcare staff have it within them to recognise and focus on a specific hazard, take a position of leadership, gather a team around them and work tirelessly until the hazard is removed.
Healthcare safety needs a ‘team of teams’.
patientsafe 
According to B. Melnyck, Ohio St. study one of the top barriers to evidenced based practice is nurse managers and nurse leadership. Barriers to EBP contribute up to 30% of complications. Nation wide this could be billions in cost. Yet, the mentioned barrier seems to have a permanent waiver for accountability. After all, we more or less have the fox guarding the henhouse situation and they have no internal incentives to change. I often try to get the media to talk about these kinds of things to little avail. Hospital deaths are one at a time spread over 2500 facilities. They get little notice. The airline industry changed radically after the Canary Island collision killed 600. Offshore drilling had Deepwater Horizon. Ironically, IOM compared hospitals to the NASA Challenger era. Is that what its going to take?
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Thank you John for your most welcome insight and comments. You’re absolutely correct about how dispersion of adverse events hinders the energy required to drive positive change: http://wp.me/p6ZAcV-11v
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It is well known that feeling safe to speak up is critical in risk reporting. As an illustration of how rare this safe environment is in hospitals, John Nance, in his book Why Hospitals Should Fly, had to invent a fictitious hospital to make his points. He also told the true story of how reassuring a subordinate crew member that he could question the pilot”s actions or raise concerns helped avert a disaster. I worked at one place where they did not like me doing the fire risk assessment as part of my timeout. This was a standard I learned a few years before and was evidenced based. It ended up being one of the bullet points in their black book. A sad commentary to what once had been a favorite facility to work at. I did have the satisfaction of telling the senior director, on my last day, how punitive the culture had become. Of course they had a bogus employee satisfaction survey to counter with. I withheld telling her that conversations with staff told the real truth. At the end of shift without warning, or courtesy notice, my id badge was disabled. Its sad how deceitful and cruel the management can be to nurses who are just trying to speak truth to power, advocate for patients and fellow staff.
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Thanks John, I just finished reading Why Hospitals Should Fly 2 nights ago and am in the process of drafting a post based on the book. A great book. We are all frustrated by the lack of change. Hopefully we may have come up with a solution – please see the PatientSafe Network at psnetwork.org
In particular read the Obstacles to Patient Safety and Fixing Healthcare Safety.
Welcome on board – we need all the help we can get. Thanks again for your comment.
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