Toward a ‘culture of safety’
LAST UPDATED: 06/19/2011 03:04
Ergonomics is making inroads in the medical profession, helping prevent dangerous mistakes.
ergonomics Photo: Yael Donchin
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.
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.
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.
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
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.
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.
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.
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.
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
Operating rooms have become extremely complex facilities, with
a myriad of surgical devices, scanners, radiation, lasers and others
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
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.
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
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.
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
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
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.”