Reports or proclamations from the Institute of Medicine, industry groups or regulators have already provided advice-perhaps more than you wanted-about what your hospital should be doing in broad terms about patient safety. I want to address what you as an individual can do.
As an executive or manager, you interact with many people each day. Your actions, behaviors and questions teach others and set the tone. One of the first things you can do to remove a lot of confusion and wasted effort from the work of patient safety is to emphasize that the aim is to reduce harm, not errors. Organizations are wasting a lot of time eliminating errors that are inconsequential with respect to harm. You do not have the resources to do it all.
You might as well focus on what will have an impact. You can reinforce the focus on harm by eliminating the word "error" from your vocabulary and substituting "harm." For example, when you review the work of an improvement team trying to reduce a particular type of error, probe with the following questions: What harm to patients are we trying to reduce by reducing this error? If we focused on this harm directly, would you be testing and implementing different changes?
Political considerations most likely influence your organization's decisions concerning reporting systems as much as technical ones do, and those considerations are universal. Last month, 61 people from 28 countries participated in a seven-day seminar on patient safety in Salzburg, Austria, led by a faculty of eight, including myself. Few if any of the faculty advocated reporting systems as a primary means of improving patient safety. Developing and maintaining them takes a lot of work.
Often the reporting systems focus on error rather than harm. You can balance the impact of large reporting systems by asking helpful questions in your daily interactions with clinicians. For example, engage a group of nurses and doctors in a conversation about safety and ask: What accident that would harm a patient is waiting to happen? Their answers will reflect their predictions and their experiences and no doubt sometimes their personal agenda. Even if you or they are not able to take immediate action, by repeatedly asking the question you will be able to identify the harm-causing conditions present in your organization and set some priorities.
Another terrific source of information about harm-causing conditions is in the "near-misses" available at checkpoints. For example, pharmacists intercept and intervene on medication orders that are incomplete, inaccurate or dangerous. From the perspective of patient safety, eliminating the dangerous orders is vital. A simple question from you can produce some useful data and send a message about what is important.
Once or twice a week, take a walk to the pharmacy and ask: What are the five most dangerous orders that you intercepted in the last few days? Even if immediate action is not possible, you will have the opportunity to acknowledge the important work the pharmacists are doing for patient safety. If you ask the question over a period of weeks, common themes will emerge on which to base some priorities for improvement.
Harm-related aims and data from the front line will not make patients safer during care unless they result in smart changes to the system. As the Salzburg participants began to realize, the design of safe systems is a difficult technical task. Someone should be assigned to keep abreast of the latest in safety technology.
Although you may not be an expert in the technical aspects of designing systems for safety, you can have a positive influence on the design efforts with just a few well-placed questions or interactions. Experts in the design of reliable and safe systems often use a three-part approach:
n Design the system to prevent failure (a breakdown in operation or function).
n Design procedures for making failures or increased risk visible when they do occur, so they can be intercepted before causing harm.
n Design procedures for mitigating harm caused by system failures when they are not detected and intercepted.
When you review safety efforts, you may hear that a particular system failure is not preventable-for example, an allergic reaction to penicillin-and hence nothing can be done. You can spark some creative thinking by asking whether the early indications of trouble could be recognized more reliably and whether the procedures for minimizing the harm could be improved.
You can also protect the safety efforts from being hijacked by the "one best approach." For example, some people in your organization may assume that implementing protocols, guidelines or clinical pathways is the only way to assure safety. In Salzburg the discussions about standard procedures, such as protocols, were lively and insightful. It became clear that standard procedures were one part of a safe system, but rigid adherence to standard procedures was neither feasible nor safe.
You can keep the development of standard procedures on a productive path by asking the following two questions: What are the two to four features of this standard procedure that really matter for patient outcomes and safety? When caregivers deviate from these aspects, what are the reasons? Listen for answers that reflect a customization of the care to the individual patient or reflect an adaptation because of a system failure such as the delay in a critical lab result. Be suspicious of answers that seem to point to uncooperative or indifferent clinicians.