Can any member of your healthcare team stop the delivery of healthcare because of concerns for patient safety?

One hospital reported to PA-PSRS that a patient’s pre-operative EKG was read by a cardiologist as indicating possible myocardial injury. The patient was nevertheless cleared for surgery by a physician. A nurse brought the EKG reading to the attention of a senior anesthesiologist, who responded to the finding with a workup before clearing the patient for surgery.

This is an example of what safety experts call a high reliability team.¹ One team member had a concern that another member may have made an error and felt confident in questioning the decision. The response was to focus on the core issue of patient safety rather than the peripheral issue of hierarchy.

In contrast, other reports submitted to PA-PSRS suggest that members of some healthcare teams are reluctant to speak up:

• A surgeon left rings on while scrubbing for a procedure in the operating room.
• A nurse witnessed a physician insert a central venous catheter without using maximum sterile barriers.
• A physician did not wash his or her hands after examining a patient with a MRSA infection before proceeding to examine another patient.
• A physician started a trans-esophageal echocardiogram before appropriate monitoring devices and suction were connected.

In other reports, team members who did act on concerns did not receive responses that indicated respect for the underlying patient safety issues:

• A surgical skin preparation tray became accidentally contaminated when a non-sterile towel touched it. The surgeon was informed of the contact, but proceeded to use the tray to decontaminate the patent’s skin anyway.
• A physician wrote an order for the patient to continue medications from home per a list that would be provided by the patient’s spouse. The medication list was obtained, but no medications were given before the physician’s next visit, in the absence of specific medication orders from the physician. The physician was upset that the patient had not yet received any medications per the original surrogate order.

High reliability organizations are characterized by a total commitment to safety, an understanding of safe and unsafe practices by everyone involved, attention to safety by all members of the team, and both a responsibility and respect for acting on potential unsafe practices.¹

On November 10, 2004, the Agency for Healthcare Research and Quality released a survey instrument that will allow healthcare facilities to assess the “culture of safety” in their institutions.² Among the questions for healthcare workers are:

• Will staff speak up if they see something that will negatively affect patient care?
• Do staff feel free to question the decisions or actions of those with more authority?
• Are staff afraid to ask questions when something does not seem right?

No set of procedures will improve patient safety if team members do not feel empowered to act when they believe the procedures are not being followed. This sense of empowerment is not an accident of hiring individuals who already have that attitude. It is the result of an effort by the organization and a demonstrated commitment from senior leadership that creates this attitude among staff.

Notes

1. Roberts KH, Yu K, Van Stralen D. Patient safety as an organizational systems issue: Lessons from a variety of industries. In Youngberg BJ, Hatlie MJ, eds. The patient safety handbook. Sudbury (MA): Jones & Bartlett; 2004:169-86.
2. Sorra JS, Nieva VF. Hospital survey on patient safety culture [online]. AHRQ Publication No. 04-0041, Sep 2004. Agency for Healthcare Research and Quality, Rockville (MD). Available from Internet: http://www.ahrq.gov/qual/hospculture/