Patient Safety: Create a Culture of Safety

February 2015

By Alexis V. Reeves, RN, CPHRM, CLNC Patient Safety Manager

It was late spring when 32-year-old Amy, a wife and mother, entered a prestigious medical center's ambulatory surgery unit for an elective tonsillectomy. Amy was not worried since the hospital where she was having her procedure performed thousands of similar procedures each year. The surgeon explained to Amy and her husband that she would be able to go home by the afternoon.

The procedure began uneventfully until the anesthesiologist attempted to intubate Amy. Within minutes, the anesthesiologist realized that he was not able to secure the airway due to swelling and requested assistance from the surgeon. The two physicians struggled while two nurses stood by with a tracheostomy kit in the ready. Minutes passed and the struggle to obtain an airway continued. The situation was critical as Amy was already given a paralytic and she had no ability to self-ventilate.

What seemed to be just minutes was in actuality 20. Finally, the physicians secured the airway, but to their horror, too much time had passed. They aborted the procedure and took the patient to the post-procedure care unit where a neurologist assessed her and ordered diagnostic tests. Unfortunately, Amy had suffered permanent anoxic brain injury. After serious consideration, her husband and family made the decision to discontinue life-support. She passed away the next morning.

What went wrong?

This was supposed to be a simple outpatient procedure, one that's performed on thousands of patients every year. Amy should have recovered a few hours after surgery and gone home in time for dinner. After a thorough investigation and hours of inquiry, a couple of key issues were identified.

First, the physicians lost situational awareness. Secondly, and more importantly, the two nurses realized what was happening to the patient, and had a tracheotomy kit ready, which could have saved the patient's life. But they were afraid to speak up. It does not seem logical that a medical caregiver would not speak up for the safety of the patient, but their inaction was linked to past negative encounters with the particular anesthesiologist on the case.

According to the National Patient Safety Foundation, the majority of "never events" can be attributed to the lack of a "safety culture" within an organization. "Safety culture" is defined as "the ways in which safety is managed in the workplace, and often reflects the attitudes, beliefs, perceptions and values that employees share in relation to safety." The culture is shaped through experiences (encounters), developed into beliefs ("I will be in trouble if I speak up") that translate into actions ("I will not speak up to avoid punishment"). Since these nurses had a history of negative encounters with the anesthesiologist, they were conditioned to believe that they would be admonished if they spoke up. So they failed to act.

Self-preservation is a normal human reaction and one that overrides many other thoughts in the moment. This does not mean that the nurses were negligent, but this high-pressured situation required more time to process what was actually happening — time that Amy did not have.

What could have been done differently?

Providing education in the "Culture of Safety" and flattening the hierarchy within workgroups can override the fear that leads to inaction. Team members must feel comfortable in speaking up or raising questions if concerns arise and the receiver of the information must be willing to accept questions and feedback in a professional manner. What happened to Amy was a tragedy, one that was completely preventable. The lesson here is to create and nurture a culture in which all staff feels safe to speak up and voice concerns. Next time you are interacting with your workgroup or team, give everyone permission to speak up for safety.

— Alexis V. Reeves, RN, CPHRM, CLNC