Toward a ‘culture of safety’

A fighter jet’s cockpit is probably the most ergonomic work environment there is. Every piece of equipment was planned to fit the human body, its movements and the user’s cognitive abilities – and was thus designed to be in the most logical place to get the job done efficiently and safely.

The average hospital is an incredibly complex mix of human capital, know-how and habits, together with drugs and other medical technologies that can heal but, if not used properly, can also cause damage or even kill. An estimated 1,000 to 2,000 Israelis die of medical errors each year; many more take ill and recover, or are victims of errors that fortunately do not take a toll.

Until ether was discovered and demonstrated in 1846 by a US dentist and made operations with anesthesia possible, many people refused to put their bodies in the hands of surgeons. But today, many people who need hospital care fear being harmed by medical errors, even if the risk is highly exaggerated.

MOST OF the mistakes that do occur, says the Hadassah Medical Organization’s Prof. Yoel Donchin, could have been prevented if medical management had established a “culture of safety.” But the health system is too often run with a risk-management mechanism that, after an error is committed, tries to minimize the financial damage of subsequent lawsuits. Donchin, a veteran anesthesiologist and an intensive-care physician, has devoted himself to patient safety for 20 years of his more than three decades at Hadassah. Even after his recent retirement from direct patient care, he remains head of the Patient Safety Unit at the Hebrew University- Hadassah Medical School.

DONCHIN HAS also just produced, with coauthor Prof. Daniel Gopher (an industrial engineering expert at Haifa’s Technion-Israel Institute of Technology), a major Hebrew volume explaining exactly how hospitals can be made safer. Required reading for hospital directors, medical department heads, nurses, medical deans, nursing-school faculty, Health Ministry administrators and others close to the field, the 431-page, NIS 114 softcover is called Saviv Mitat Haholeh: Handasat Enosh Uvtihut Betipul Refui (Around the Patient’s Bed: The Human Factor and Safety in Health Care). It was published by Carta, the Hadassah Medical Organization, and the Technion.

The authors said the widespread hospital policy of trying to assign blame for medical errors is harmful.

There are only extremely rare cases in which someone intentionally causes harm or is incompetent; the main problem is an “unfriendly environment” – one not suited to working safely – and lack of staff coordination, Donchin and Gopher argue.

For example, hospitals for many years have not insisted that surgical teams post checklists prominently in operating theaters that everyone is required to go through, no matter how tiresome. The patient’s name, blood type, possible allergies and other details are checked with him and written records; don’t forget not to operate on the wrong eye, arm, leg or other organ by mistake. Carefully count the number of pads and surgical tools used to make sure they are not left inside after an operation.

The key is to treat each patient like a human being – or your own child, mother or grandfather – and give personal attention and compassion. Donchin introduced the written checklists years ago in Hadassah operating rooms, and they have minimized errors; other centers have adopted them.

Doctors and nurses have often carried specimens of blood, urine and other substances in test tubes in their pockets; Donchin introduced disposable, light boxes for holding them instead. Nurses’ workstations have been redesigned so that the proper equipment is accessed despite the pressure of time. Maintenance staff can be taught to work more efficiently to reduce the risk of infections.

Even surgical garb and nurses’ uniforms can be redesigned – with staffers’ input – to make them easier to wear and use, including changing the location and number of pockets. The book includes numerous illustrations, flow charts and line drawings.

Hospitals are noisy places, and staffers are constantly exposed to distractions. Doctors and nurses are regularly asked seemingly urgent questions by patients, relatives and friends while in the middle of taking care of another patient. To that, add the number of times staffers get a call on their personal or hospital cellphones. This distraction is understandable, given the serious shortage of medical personnel and the fact that many are overburdened, but such distractions can lead to medical errors.

THE AUTHORS devote much space to other critical problems, such as how medications, infusion solutions and injections are packaged. Those that have the same color and consistency but are different drugs can be deadly . Thus one dosage might be placed in the same type of package as one many times more concentrated. The pharmaceutical companies and the hospital’s own pharmacies must give more attention to giving each product unique forms so they are not easily confused.

A chapter is devoted to magnesium sulfate, which was prescribed for a cancer patient at an unidentified foreign hospital in June 2001. The woman was injected with 100 times the required dosage, and it killed her. Thinking about how to prevent such tragic errors, the authors devised manual calculation forms that could easily be filled in to calculate how much powder should be added to dilute it and at what the rate the infusion should drip into the patient’s arm.

Various fail-safe mechanisms are suggested.

Just changing the height of counters in nursing stations made them more comfortable for preparing medications while standing up. Replacing regular refrigerator doors with transparent ones helped nurses see the various labelled raw materials inside without even thinking about them and thus reduced errors, the authors reported.

Nurses and doctors must also have easily accessible, computerized databases to obtain background on some of the thousands of medications if they are not experts. Many mistakes are picked up when doctors, and especially nurses, carefully brief those who arrive to take over their shifts, the authors note.

The authors led extensive research on hospital departments around the country to discover the causes and extent of errors. Observation teams spent days following every staffer and action to record what exceptions were made to the rules and protocols, even if they did not cause any harm. With the help of Gopher, the ergonomic expert, suggestions were made to change habits and make department safer.

Intensive-care units are microcosms of the whole hospital environment, but more intensive and pressurized, they write, and such units are frequently understaffed and overpopulated with seriously ill patients. Observers listed 8,178 activities in 24 hours following 46 intensive-care patients in one hospital department; 78 mistakes were identified per patient during this short time. Obviously, these rarely resulted in deaths, but any errors are to be discouraged.

Because nurses have ongoing, regular contact with patients, they were involved in 84% of the errors, compared to just 3.8% by physicians. But as doctors usually give the orders and nurses carry them out, the share of mistakes committed by doctors was 10 times that of nurses compared to their activities, the authors disclosed.

Operating rooms have become extremely complex facilities, with a myriad of surgical devices, scanners, radiation, lasers and others equipment.

The teams must be as coordinated as a symphony orchestra for them to perform optimally. Distractions to the average doctor or nurse in a surgical theater were counted by observers as happening 10.3 times per hour.

The story is told of a seven-year-old boy abroad who was scheduled to undergo surgery for removal of a benign growth in his ear; tragically, he died after his blood pressure surged, his pulse quickened and lung edema seriously reduced his oxygen supply. He was rushed to the intensive-care unit, where he was found to have suffered brain damage and died.

Unusually, the nurse in charge of risk management locked the operating room and acted as if she were a detective at a murder scene. Collecting all the unmarked syringes and solutions and nurses’ assistance trays on the tables, she sent them for analysis, and discovered that a syringe that should have contained lidocaine (a transparent anesthesia solution) instead contained pure adrenaline, also transparent. The amount killed the boy. The lesson was learned: All syringes would have to be marked. It seems so obvious, but that terrible day, it did not appear so to the operating staff.

Neonatal departments that take care of the tiniest babies are among the most difficult places to work in modern hospitals. Infections can easily spread. There are too many incubators in small spaces, and too few nurses and doctors, and the helpless newborns need constant supervision and care. The beds are too close to each other due to overcrowding, increasing the risk of confusion and of staffers bumping into each other.

Observers found the medical staffers to have high motivation and a sense of mission, despite the heavy burdens in their job. But much can be done with better ergonomics, improved communication and – of course – more manpower. The State Comptroller has warned of this several times, but numerous hospitals have been unable to improve the situation.

Emergency rooms, which are also highly pressured, can gain much from a better human/computer interface, they write. In addition, changing nurses’ shifts can help. The head of one emergency department in the center of the country noticed that the number of patients was heaviest between 10 a.m.

and 2 p.m. Instead of dividing nursing shifts into three simultaneous ones a day, she decided that one nurse start her morning shift two hours late and end it two hours late, while a second nurse begin her shift an hour later and end her work three hours after the end of the regular shift. Breaking the uniformity allowed the nurse in charge to make better use of staffers at the most stressful time.

ENFORCING RULES, such as taking blood safely and preparing infusions safely, in a “friendly” way rather than making accusations and assigning blame, was found to be much more effective in encouraging proper behavior. This policy reduced errors and improved safety by 30% to 40% while helping reduce hospital infections. Paper forms are still needed in this computer age, and must allow the collection of clear and selective information, create mutual understanding among medical teams, and use mental aids to boost recall. Medical staffers will never be perfect, the authors write, but they can definitely improve hospital care.

Each department’s “climate of safety” must be examined with questionnaires, measured, assessed and compared. These data can predict the nurses’ and doctors’ behavior in promoting safety in both routine matters and emergencies, they write. This can lead to prevention of errors instead of just dealing with them.

Carrying out simulations with computerized equipment is always preferable in training before trying things out on patients, Gopher advises.

Modern medical treatment is compared to a relay race, in which each runner passes the stick to the runner after him. But medical “runners” tend to drop the “stick” frequently, thus there is a gap – a lack of continuity – in treatment that results from changes in shifts, treatment by members of more than one team, they write.

“A new and unique field of knowledge – medical ergonomics – is developing today,” concludes Donchin.

“It is a vital field, as medical systems deal with the organism and not the mechanism. In many situations, medicine is unable to give an accurate and quick diagnosis. The medical system is not a cockpit, a production line... or a weapons factory. Our system is full of surprises and unpredictable anatomical variety.”