Patient Safety: Lessons Learned
By Alexis V. Reeves, RN, MBA, CPHRM, CLNC, Director of Patient Safety Operations & Transformation
When a culture of patient safety exists, team members will feel comfortable to speak up, listen when concerns arise and be willing to accept questions and feedback in a professional manner.
Create a culture of listening
When adverse outcomes occur, you can almost always guarantee that a communication failure was a contributing factor. This is not unique to health care, but is common in all complex organizations. When we think of communication failures, what comes to mind is the transmission of erroneous information from one individual to another, which in turn is acted upon or ignored, leading to an error. However, review of data shows that errors most often occur when the information is given but perceived differently, or important cues are pushed aside by the message receiver due to personal assumptions or biases. This misinformation occurs when a culture of safety is not ingrained in the individuals within an organization. A “culture of safety” breakdown is more than just being afraid to speak up. It goes much deeper than that. Even when individuals do speak up, they may be ignored or disbelieved. The following example clearly demonstrates this point.
When a surgical patient was transferred to the floor post-procedure, a nurse (RN) noted a change in the patient’s mental status and that he was persistently tachycardic for no known reason. The RN reached out to the patient’s physician to report the changes, but because of the patient’s baseline behavior, the concern was dismissed as the patient “just being weird.” The RN was not satisfied with the explanation and continued to escalate with concerns of infection, but continued to be dismissed. Not to be deterred, she continued to voice her concerns, sensing that “something was not right.” When the patient was being readied for discharge, she stepped up her escalation. Finally, the physician agreed to work the patient up for infection, but the results came back negative. Still unconvinced, the RN continued to voice her concerns when tachycardia continued. Since the patient was scheduled for discharge, the physician opted to obtain an x-ray, which showed a retained foreign object (RFO). The patient was promptly taken back to the OR, and ultimately discharged successfully.
What went wrong?
First, the physician made the assumption that the patient was “just strange” at baseline, and the manifestation of the symptoms were based on the patient being “strange.” Second, the physician dismissed the RN’s concerns that something was wrong. Many less-persistent nurses would have stopped after their first attempt to escalate an issue was dismissed. If that had happened, the patient may have been sent home without the discovery of the RFO, which may have led to infection and possibly sepsis. Instead, this RN continued to escalate even after the initial tests yielded a negative result. The ability of this nurse to continue to speak up demonstrates a positive safety culture. But the unwillingness of the physician to listen to her concerns and follow-up promptly demonstrates the opposite.
To prevent negative outcomes, every individual within an organization must understand the culture of safety and how it translates into everyday practice. Appropriate education in “culture of safety” and flattening the hierarchy within workgroups can override the fear that leads to inaction. Team members must both feel comfortable to speak up and to listen when concerns arise. The recipient of the information must be willing to accept questions and feedback in a professional manner. The lesson here is to create and nurture a culture in which all staff members feel safe to speak up and voice concerns, and to listen to each other deeply. Next time you are interacting with your workgroup or team, give everyone permission to speak up and listen for safety issue.
What could you do?
To understand the culture in your department, we are requesting that all physicians participate in the
2017 Stanford Health Care Culture of Safety Survey, available from Oct. 30 to Nov. 19. The organization would like to understand the opportunities and challenges that physicians face daily. The results will be used to develop a robust program that addresses your concerns. In the past, physician participation in this survey has been minimal, but physicians are an integral part of the health system and we need your participation. Please look for more information on the Culture of Safety Survey coming soon.