A culture of safety

Everyone makes mistakes, and some can be lethal, but staffers at Jerusalem’s Hadassah hospitals are talking about their errors and working to reduce them.

November 21, 2010 00:46

YOEL DONCHIN 311. (photo credit: Judy Siegel-Itzkovich)


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Medical professionals tend to be a conservative bunch who like to do things their way, despite the fact that there may be safer and better techniques.

In 1847, Hungarian physician Ignaz Semmelweiss discovered that handwashing by obstetricians between the treatment of one patient and another significantly reduced the rate of deadly childbed fever. But even today, many doctors and nurses around the world still fail to carry out this vital elementary practice and spread nosocomial infections (infections due solely to treatment in medical facilities). It isn’t that they don’t understand; the main reason for this reluctance is that constantly using soap and water dries the hands, and dispensers of alcohol gel (that doesn’t cause chafing) are not located everywhere patients are.

Hospitals want to reduce errors and laziness that could harm patients, but are often reluctant to appoint independent senior staffers for this mission. Even less do they want their errors to become public knowledge.

The Hadassah Medical Organization annually holds a clinical presentation by its Center for Patient Safety, inviting senior personnel and even health reporters. “Every department in our Ein Kerem and Mount Scopus campuses presents its successes annually,” said Hadassah Medical Organization director-general Prof. Shlomo Mor-Yosef, who attended the presentation in the packed Ein Kerem auditorium earlier this month. “But the Center for Patient Safety presents our failures.

Unlike any other hospital in the country, we have two full professors working independently, one – Prof. Yoel Donchin – devoted to the preventing of errors and the other – Prof. Mayer Brezis – to improving quality.”

AWARE OF the need to encourage medical staffers to sanitize their hands regularly, the Hadassah Medical Organization developed its own product, called Hadassol, and packages it in small plastic bottles that can be worn on the belt. It contains 70% alcohol rub and an emollient cream that moisturizes the skin without fatty, sticky additives. It is cheaper and better than commercial sanitizers, Donchin said. “We make it blue so that nobody will make a mistake and drink it,” he added. Brezis added that medical staffers’ computer screensavers display messages reminding them to sanitize their hands between patients.

Mor-Yosef added that he sees patient safety as a central topic. “We are not perfect. We want to improve. We need to improve communication among department heads and others.” The two Hadassah University Medical Centers deal with a million patients a year. “Errors repeat themselves. Our large staff come with different levels of education and ability. We aim to discover mistakes and create a system with fewer errors, but one can’t run a health system that has no errors.

Our aim,” said the director-general, “is to send patients home healthier – or less sick in this era of chronic illness – than when they arrive. It is not simple for an institution like hours to allow these two professors to do whatever they want.”

DONCHIN IS a veteran anesthesiologist, firstaid expert and author, as well as a safety expert who launched his mission two decades ago, when it was almost non-existent in the world, let alone in Israel. “Other hospitals have been interested primarily in risk management,” he said, referring to efforts aimed at reducing lawsuits for negligence or malpractice, or to covering up errors. But this is very far from concentrating on preventing errors and promoting safety to the patient and employees.”

Many hospitals fail to learn from their mistakes.

For example, he cited a tragedy at Seattle Children’s Hospital in the US state of Washington in which a fragile child received 10 times the prescribed amount of a common drug and died. The next year, another child died as a result of the same error.

“Our approach is different from those in most other hospitals. We are proactive. We conduct observations of what goes on in the departments to find out where things are done that can harm patients, and design ways to minimize them. We look at processes to prevent things from going wrong. We do it without fancy technology. Talking to staffers, posting signs and using checklists can bring improvements.”

HADASSAH STAFFERS do not fear that if they report an error they or others had committed, they will be punished or even fired.

“Friendly enforcement” encourages them to tell Donchin what happened. Only if a patient was really harmed – by breaking an arm when falling out of bed or worse, for example – will the error or accident be officially reported. A nurse may have given a medication at the wrong time or at an improper dose without harm to the patient; Donchin said he should be told about such incidents without the informer or those involved being afraid of castigation.

“I can walk into any department, observe and ask staffers questions. I have done it almost full time for years. I am completely independent,” he said. “Senior managers do not intervene. Staffers tell me if they made a mistake because they don’t want them to occur.”

His job involves a lot of “human engineering” to understand how the mind works and how to change habits. It means establishing a culture of safety.

He can’t say how many errors are committed at Hadassah hospitals.

“Nobody knows. But we really don’t aim at statistics; we want to prevent the incidents.” The Health Ministry, said Donchin, is the regulator of the health system and the owner of state hospitals, and it also makes mistakes, so it doesn’t have the ability to promote safety.

“I have proposed the adoption of our safety program to a dozen health ministers and ministry directors-general, but nobody has done anything. They say they have no money for this, but only for quality control.

There isn’t one ministry staffer who devotes all his time to safety.

“THE MINISTRY has cited the figure of 2,000 patient deaths per year from errors, but nobody has a clue. The companies that insure medical staffers are of course very pleased to see newspaper reports of such cases, as this enables them to raise premiums.”

While hearing hospital doctors discuss errors that harmed or could have hurt patients is very scary and could induce people to avoid hospitals, Donchin insisted that “there are 500 or so deaths on the roads every year, but nobody doesn’t decide not to travel because of this. In most cases, everything goes well; harmful errors are a small minority.” Donchin, who has reached retirement age, will soon stop his anesthesiology work, but Mor-Yosef has asked him to “return” on contract to continue his safety and error-prevention work.

AMONG THE changes that Donchin initiated are a mandatory briefing of operating room staffers with a printed checklist in the form of a large sign, easily read from a distance, attached to one wall. Before each operation, the team is required to go through the list to ensure that the patient is correctly identified, the correct organ or side to be operated on is named, and the blood type is checked and rechecked, noting whether the patient is allergic to a specific drug, if a biopsy needs to be taken or an X-ray done during the procedure (which will make the surgery take longer), the patient’s required position and other issues that if not clear could endanger the patient. In most cases, the person to be operated on is still awake, participates and sometimes makes comments or corrections.

Occasionally, when it’s a routine operation, staffers might say – ‘Forget the briefing; let’s go ahead and operate!’ – but Donchin insists on going through the procedure every time.

The Health Ministry has told all the hospitals to use a printed checklist (not a formal briefing), “but I don’t know much it’s enforced.”

Donchin also removed potentially harmful potassium from departments, requiring it to be kept in a separate cabinet; potassium is given only to certain patients, such as those undergoing chemotherapy or those who don’t eat; if given to anyone else, it could be fatal. In a separate cabinet, it is handled more carefully, and users are required to make special calculations of dosage, he explained.

But he still hasn’t managed to persuade Hadassah staffers not to use their cellphone while treating a patient.

“I taught the first safety course for doctors in the world at Hadassah. The situation here is certainly better than it was 20 years ago, but still, despite published studies that measure efficacy, some doctors are not convinced that prevention will make a difference. Yet some Israeli hospitals and the health funds are beginning to show interest.”

Years ago, Donchin “by chance” met Prof. Dan Gopher, an industrial engineering expert at the Technion-Israel Institute of Technology in Haifa. “I learned from him and did two sabbaticals with him at the Technion.

We wrote a book together and worked in Emek Medical Center in Afula and Rambam Medical Center in Haifa to spread our ideas and reduce errors.”

DONCHIN SAYS he is planning to establish a School for Safety in the Hebrew University- Hadassah Medical School in Jerusalem that would be open to teaching other hospitals and medical students about proactive prevention of errors.

Gopher, who attended the Ein Kerem presentation, said that in the old days, only a few doctors and nurses actually treated patients.

“Today, medicine is very technological and complex – full of data. It requires a team effort, and every procedure is divided into steps, some done simultaneously. There are employees of varying medical backgrounds, and medical care is very expensive. There is always the desire to purchase every new technology. But,” said the Technion engineer, “there is little investment in an environment friendly to the medical team. They work in a user-unfriendly environment. The solution is the engineering of human factors to improve patient safety.”

He compared the average hospital or clinic to the planning of an aircraft cockpit. “There is so much advance planning to make it work and minimize errors. But you can’t say the same for health facilities. They are built like a patchwork quilt, piece by piece. It depends on when there was money to buy equipment.

There may be two different monitors near a patient’s bedside, each working simultaneously but not in coordination. There is not enough communication or clear division of labor,” Gopher said.

Hadassah Dr. Sigalit Mudahi reported to the audience that much can be done to reduce errors in its labs, which process 2.5 million samples a year. It was routine for staffers to transport vials with samples of blood, urine, stool and other substances in the pocket of their white coats, which was certainly not optimal. A disposable, recyclable carton was designed to replace this. As there was a wide variety in the quality and suitability of samples taken, she continued, staffers were sent to short courses on Hadassah’s Intranet site to train them to do it properly so fewer would be rejected by the lab workers.

DR. LIMOR GOLDENHIRSCH conducted observations in the emergency room for six months for her final MD studies project. She and colleagues watched the movement of staffers, patients and materials within a small area and listed everything. They found cases in which patients had became disconnected from monitors or left in the X-ray department alone, bedsides had been left down, and patients taken to the wrong place. Many signs were not translated into languages understood by most patients, and X-ray technicians who didn’t understand what the doctors ordered sometimes performed a different X-ray than those desired. Her findings led to improvements, and despite all the revelations, Hadassah hospitals are probably safer than many of its counterparts.

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