Why patient safety is such a tough nut to crack

Visibility

Safety issues in healthcare are often not clearly visible. There is often no discernible distinction between a patient who has died because of a preventable adverse event, and any other deceased patient.

Further, even if a problem is recognised at the level of the individual patient, its magnitude can remain hidden from the healthcare professionals involved. Lucian Leape called this “the tyranny of small numbers”: if 400 medical specialists work in a hospital and 40 patients die each year as a result of unsafe practices, each doctor will experience an avoidable death about once every 10 years.9 Even if this event has a major emotional impact, it may well be seen as a freak occurrence rather than a daily problem.

Research showed that healthcare professionals thought the percentage of adverse events in healthcare was significantly lower than the To Err Is Human report claimed, even though many had personal experiences of these events.10 This shows a discordance between the real extent of the problem and the extent felt by the professionals who could have the largest effect on reducing the problem.

Low visibility makes it hard to create a sense of urgency. Safety thus often loses the battle for attention against more visible problems such as financial deficits, obtaining new technology, or labour shortages. Low visibility also makes it difficult for executives and professionals to justify the allocation of large resources to improving patient safety, not only to external stakeholders, employees, and colleagues, but even to themselves.

Ambiguity

The second challenge is the high level of ambiguity. Evidence for a clear cause and effect relation is often inconclusive. Consider this example: in our hospital a nurse inadvertently administered adrenaline (epinephrine) instead of heparin through an intravenous line to a very sick paediatric patient. The patient went into cardiac arrest and was resuscitated successfully but died three days later. What was the cause of death? The half life of adrenaline is far too short for it to have had any effect three days later, and though theoretically the adrenaline overdose could have caused myocardial damage, it could just as well have been the patient’s prior illness that led to death. A mistake with grave consequences for the patient clearly was made, but even here we cannot be certain that the error in fact caused the patient’s death.

Another example of the ambiguous nature of the patient safety problem can be seen in the discussions about the role of systems versus the role of individual behaviour. For a long time bad outcomes were typically attributed to individual so called bad behaviour. Research on morbidity and mortality meetings showed that most adverse outcomes were blamed on an individual professional.11 Since the publication of To Err Is Human more and more healthcare professionals have embraced the concept of system failure as the cause of adverse events. The problem, however, is that both sides are right: almost all adverse events in healthcare can be attributed to both system errors and individual errors, depending on what side of the discussion one stands.

Complexity

In such complex and tightly coupled organisations as hospitals, practically everything can have an effect on patient safety: from temperature of tap water to logistics of meals, from floor tiles to education and training. Donald Berwick describes the consequence: “A hospital that wanted to make patients truly safer would have to involve almost all departments, support systems, and patterns of activity. Dozens of habitual systems would have to change—rounds, record keeping, meetings, training programs, policy manuals, and review procedures, to name but a few.”12

As a consequence, one can feel overwhelmed by the sheer magnitude of the problem. This can lead to fatalism: that it is useless to make one aspect of care safer, because the problem will only strike somewhere else. It can also lead to heated discussions between professionals and executives about which safety problem is the most urgent. Executives might think compliance with regulations (such as hygiene protocols) is paramount, whereas professionals may want to focus on proper equipment and staffing levels. Both can argue the importance of their issue and both can be right at the same time.

Autonomy

Professional autonomy is conducive to patient safety. Healthcare professionals are responsible for the safety of their patients and feel strongly that way. However, this positive characteristic has a negative aspect: physicians often see their autonomy as an unconditional requirement for delivering good care. Consider the example of a surgical patient on an intensive care ward. The surgeon can be adamant that a certain therapy should be applied for “his” patient, while the intensivist, who feels just as responsible for the patient, is convinced another therapy is more appropriate. Both specialists think their autonomy gives them the right to supersede the other’s order. It is not unusual in these cases that the care for the patient will oscillate depending on which specialist has seen him last. Even when autonomy impedes safety, restrictions on autonomy will not be easily accepted.13

Another aspect of autonomy that frustrates safety is the culturally ingrained reluctance to correct an erring colleague. There are many painful recent examples of dysfunctional physicians continuing their practice for years without correction by their peers, who were well aware of the problem. As in other professional groups, such as judges, autonomy has contributed to a so called non-intervention culture.14

This limited role of peer control concerns senior professionals in particular. In an anonymous patient safety questionnaire sent out to all our physicians and nurses, we asked if the respondent would speak to their superior if the superior behaved in a manner that was clearly unsafe for the patient. Of the 135 residents that returned the questionnaire, 40% stated that they would not. In 1991 Albert Wu found that only 54% of residents had told their supervisor about a serious mistake the resident had made.15 Volpp and Grande later described the negative effect of senior faculty on openness about safety: “the presence of many senior faculty members at these [morbidity and mortality] conferences inhibits frank discussion among house staff of the possible role of errors in bad outcome.”16

Healthcare professionals can experience patient safety interventions proposed by someone outside of their domain, like healthcare executives or professionals from another specialty, as a threat to their autonomy.

Criteria for success

To be successful, these interactive processes must meet several criteria. Firstly, participants must have influence among their peers, which will be conducive to the dissemination of the results. Secondly, it must be regarded as safe and attractive to participate. This can be achieved by, thirdly, creating enough room during the process for professionals to define what they see as the main problems and solutions. Fourthly, management must be willing to approve the outcome. Finally, participation at the start can be made mandatory, but professionals must have freedom to step out of the process if they think it’s going the wrong way. This might seem to create a risk for the enterprise, but the exit option is often conducive to the willingness to participate at the start of a process. During the process, the exit option will probably not be used: the longer a participant is engaged, the more they have invested and the harder it is to opt out.

The multiple perspectives of professionals on problems and solutions can be discussed in these processes, and can result in improvements that work and are supported by both professionals and management. The professionals’ energy is thus shifted from resisting what may be perceived as external interference to finding ways to tackle the four key challenges and improve patient safety in their own arena.

For example, by having healthcare professionals execute root cause analysis in multidisciplinary teams, safety issues become more visible to them, they are compelled to consider each other’s perspective and they learn to handle the ambiguity and complexity of factors influencing safety, while maintaining their autonomy. The quality of such analyses at the ward level may be lower than that performed by a professional outsider, but it can tremendously engage professionals and empower them to implement multiple sustainable safety interventions.