Bare-bones resources’ effects on safety, best practices worry clinicians
Part 2: Time to view errors as opportunities, not punishable offenses
What is happening to patient care as health facilities strive to do more with less? Clinicians and quality managers who discussed that question with QI/TQM grant that fatal or life-threatening errors — the headline screamers — are a concern. Continual efforts go toward spotting potential problems and integrating safety processes to keep them from harming patients.
A bigger worry for many, however, is what goes undone. Clinicians fear that patients receive too little attention from caregivers with skills to match the severity of illness among today’s inpatient populations.
But Paul Wallace, MD, director of the Clinical Practice Guidelines Program at Kaiser Permanente in Portland, OR, charges that we’re going to swim upstream on all of it until we change "the public packaging" of errors. The news media jumps on such events with a punitive attitude, he contends, "and when it’s viewed as what’s broken about health care, you’ll have less opportunity to prevent errors."
The nursing community is studying the impact of personnel shortages on patient care, but definitive data are yet to come, asserts Marge Freundl, MSN, RN, CNAA, corporate director of disease management at St. John’s Health System in Detroit. One problem, she says, is the ratio of unlicensed personnel to licensed personnel in acute care environments. However, the industry has selected outcome measures that may or may not be adjusted to current rates of patient and staff turnover. Two widely documented quality indicators — fall rates and medication errors, for instance — are easier to catch than what’s left undone, Freundl adds.
Christine Kovner, PhD, RN, associate professor, at New York University, Division of Nursing in New York City, voices similar concerns. "There may be more errors of omission than commission," she says. Action-based errors such as giving a patient the wrong drug have garnered enough attention in recent years that they might pose less danger now than areas of care.
For example, hurried caregivers might not do the best job of monitoring pain control meds, so it takes longer for a patient to get up and walk after surgery, she explains. "Sometimes catheters stay in longer than they should because it’s easier than getting a patient up to urinate every two hours."
In ambulatory care, time pressures bring a different sort of concern. "Clinicians worry more about how they can get everything done that they want to do for the people they see without making my members wait,’" Wallace notes. "This tends to run into long days." (See "Research: Patients do better when nurses are around," p. 79, for recent findings on the presence of licensed nursing staff and patient outcomes.)
Until you recognize a risk, you can’t design measures to prevent it. Freundl questions whether we’ve identified, much less know, how to track the risks inherent in the current scenario: "There’s more to do for patients, and we have shorter hospital stays. You could have 25 steps in the path between medication order and administration to the patient — but sometimes the doctor gives the wrong order."
Quality specialists like Eileen Craig, RN, MSN, CPHQ believe that one solution is to re-create the workplace where the new realities play out. Craig, director of nursing performance improvement and clinical risk management at Our Lady of Lourdes Medical Center in Camden, NJ, looks for ways to compensate for the decreasing amount of time to rethink clinical judgments.
For example, easy access to high-risk medications such as potassium chloride is just an accident waiting to happen on an acute care unit, she says. So instead of installing elaborate safety checks, her facility took the compound off the units. Orders for the substance go to the pharmacy from which they’re dispensed case by case.
In referring to "changing the public packaging of error prevention," Wallace says QI professionals need to recognize that errors occur and regard them as improvement opportunities. "In a punitive environment, however, the likelihood of identifying errors is remote," he contends. "If we put error prevention under the quality improvement umbrella, the likelihood of recognizing and rectifying errors is greater."
In fact, Craig notes that the literature documents a link between non-punitive environments and safer patient care techniques. Caregiving mistakes are usually system-based problems, not individual ones, she adds. But a clinician’s reflex to brace for retribution is hard to change. At Our Lady of Lourdes, they’ve worked on it for about 10 years, she says, and people finally believe they won’t get their wrists slapped. "We have a hot line, and we’re encouraging people to report near misses with medications or equipment," Craig says. "If people report it, we can look at the process. Because, if it happens to one person, it can happen again."
When quality managers and clinicians ask, "If we created health care delivery processes once, why not re-create them to serve today’s needs?" they come up with effective error-prevention techniques. Here are a few examples:
• Positive redundancy. "In any system where there is complexity, such as with medications, it’s safe to build in redundancy. The better the upfront support for the clinicians, the fewer mistakes those redundancies will have to catch," Wallace says.
An example of upfront clinician support is Kaiser’s electronic record, which lists each member’s medications. "It’s not only critical for our clinicians to ask members at each appointment about their medications," Wallace says. "It’s critical for members to understand that we’re not just keeping poor records. Asking each time helps us pick up inconsistencies or changes in their medications."
• Multiple chart reviews. At the Evansville, IN-based Deaconess Hospital Inc., Joyce Thomas, PharmD, supervisor of clinical services for the Pharmacy Department, observes, "We are concerned not so much about error, but about too many patients and too little time to review therapy for everyone as we would love to." Before signing off on any drug order, though, pharmacists double-check the dose calculations against the patient’s height, weight, and allergy data. "And then we stand back and ask, With this patient’s profile, does this drug make sense?’" Thomas explains.
But sometimes priorities compete, she concedes. With nursing staff at bare-bones levels, there is a bottleneck in processing patients and transmitting their height, weight, and allergy data to the pharmacy within the time target for administering the first dose of medications. "I’m not going to lie and say that every drug is dispensed having the allergy, height, and weight in front of the pharmacist. Sometimes it is not," she admits.
Another check, however, is the rotation of clinical pharmacists among the units. So a different set of pharmaceutical eyes looks at a chart each day. "If we do make an error, this system minimizes the duration of it," Thomas says.
To maximize its pharmaceutical resources, Deaconess prioritizes patients for clinical pharmacy reviews. Criteria include advanced age, decreased renal function, numerous medications, and orders for powerful or potentially dangerous medications such as Coumadin. Antibiotic therapies also come under review for medical benefits and cost. Thomas explains that a physician can easily overlook the opportunity to switch a patient off of intravenous antibiotics costing $64 per day on to oral antibiotics at $8 per day.
• Intelligent resource allocation. At Our Lady of Lourdes, Craig and colleagues designed alternative staff and resource use to keep nurses at bedside. The Diet Express program, for instance, gives the nutrition associates responsibility to convey patients’ menu requests to the kitchen and to re-schedule meal delivery around test appointments. This gives the dietary staff opportunities for patient contact and relieves nurses of handling food requests. Patients love the extra accommodation.
The transportation department delivers specimens and supplies as well as patients. Each unit has a bin for transportation associates to check on regular rounds. When an associate picks up a patient destined for the lab, for example, he or she checks the bin for any deliveries to the same, or a nearby location. Technological resources play a role as well. Nurses carry phones. Thus, they can take calls as they come and answer simple requests immediately. (See "A day in the life of a nurse: Real vs. ideal," p. 81.)
We have much to learn about the right staffing levels and skill mixes for the best outcomes from today’s medicine. But Kovner contends we can still get a lot of mileage out of what we already know. For example, she observes, "We know ways to assess pain levels and control patients’ pain. But you can consistently go to institutions and find patients in pain. If we will start applying evidence-based medicine, our practice of medicine will improve."
What’s going to push the industry from cost cutting to quality-based budgeting? Kovner answers, "When employers start basing their purchasing decisions on quality rather than costs, they will motivate hospitals to pay more attention to quality." (See "Mortality, staff levels show link in pharmacies," p. 82.)
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