On April 10, 2016, at the 40th annual meeting of the Association of Veterans Administration Surgeons (AVAS), L.D. Britt M.D., FACS, (Chairman Department of Surgery Eastern Virginia Medical School (EVMS) and Past President of the American College of Surgeons (ACS), welcomed the membership to Virginia Beach / Hampton Roads, VA. In his address, Dr. Britt expressed his concern, as a surgeon, and as a member of The Joint Commission, that we have made little progress in the prevention of adverse events in patient care over the past decade. As he noted, "there still remain documented challenges with respect to patient safety and adverse events (including “never events”). For example, a foreign object is left inside a patient 39 times per week, and wrong procedure / wrong site surgeries occur more than 40 times per week." Dr. Britt issued a challenge to our members to address this issue in Veteran's Health Administration (VHA) Hospitals. He expressed his belief that the VHA is an ideal environment to set the example for the rest of the nation in accomplishing the reduction or elimination of adverse events.
At the conclusion of Dr. Britt's address to the AVAS, the membership posed the following questions regarding his view on the current state of patient safety:
You stated that, in spite of all our best efforts, there has been relatively little progress in the prevention of adverse events in healthcare. With all our technology and awareness, why is it that we still cannot achieve patient safety?
Dr. BRITT (LDB): We have a dysfunctional system with too many distractions. In the time- out there is no concentration on the actual tasks. I believe that we are not systematic. We need to fix the system first! We are a disparate federation consisting of insurance providers, hospitals, nursing, medical providers. To fix the problem, we need to integrate the system. We need to all work together to correct this problem.”
Is the persistence of adverse events in healthcare a symptom of bad apples or bad orchards? Do you believe adverse events occur because we are simply not smart enough to do what we are supposed to do or is there more to the story? If there is more than simple non-compliance, what is the answer?
LDB: “You are asking the wrong question. You need to ask ‘why are they not doing it right in the first place?’ You wouldn’t work for Vince Lombardi and keep making mistakes. If you become an outlier, you get a chance to redeem yourself. You get a chance for remediation. You relearn or you move out! You are no longer on our team! They can find another place where you will fit in and function but not with us. The true system should be able to effectively address these adverse effects. You cannot give the system a ‘PASS’ when it allows this to happen.”
Why is communication still a major barrier to reduction in adverse events in healthcare? Is team training, communication training and human factors training the answer or is that simply a portion of the equation?
LDB: “The answer is both- these are all factors in the equation. Team training is only one component. Communication is clearly a key aspect. You cannot fix this without improving communication. BUT, this should not be a top-down process. There must be equal footing. We need a circular, cooperative communication process. We need to reconfigure the way we communicate. If the IOM reports that adverse events have increased from 98,000 to 200,000, then we have a problem. Why? It is likely that optimal communication has not been achieved.”
Since health care has attempted to model team training after the aviation model since the 1990's, should we be bragging about the results noted by Salas or appalled? It appears that while aviation is a model to build from, should we not develop a unique model that fits what we are actually doing in the OR, ICU, ED, clinic, and wards? Background: In 1992, Alan Diehl reported a 36 to 81% reduction in aviation and Coast Guard cutter accidents directly related to institution of crew resource cockpit training. (1) In their 2016 meta-analysis of team training in healthcare,' Salas's group found that team training reduces medical errors by 19%. They reported that 19% of trainees had an increase in their positive attitude to team training.(2)
LDB: “We may not be hitting a home run BUT we need to build upon these results. This requires a multidisciplinary approach and team training is just one component.” “I know Richard Karl well. So if he says medicine cannot function in an entirely aviation-based model, you‘d better believe it. He is a pilot, so he should know. AVIATION IS NOT THE SAME AS MEDICINE. Medicine is much more complex. Aviation typically has a relatively stable environment when planes are operational. A weather report changes infrequently. In aviation you don‘t have to worry about comorbidities or secondary changes. There is no parallel to what we have in medicine. There are always unknowns in medicine.“
Does the term “captain of the ship” exist in a healthcare HRO? In this modern age of teamwork, how can one oversee processes that we do not perform ourselves, but could result in a bad outcome, and also maintain the essence of teamwork?
LDB: “We cannot think of ourselves as captain of the ship. I think of a surgeon as being the key member on a relay team. I am not captain of the team, but I am ONE of the team members. However, after the baton is passed off, you cannot relax. The oversight of the entire process is the responsibility of the surgeon. So wherever the patient is coming from or going to, the surgeon needs that oversight.
Is focus on raw data, single negative events or documenting the checklist instead of focusing on a safe practice culture distracting staff from progress towards patient safety improvements? If so, what can be done to rectify this concept of punishing people for a single event?
LDB: “In your example, the data is not being taken into context. You must always place the data in context with the patient and the environment. At the end of the day, someone needs to review the events and say ‘a mistake was made, but the patient survived! ‘ Everyone knows that the chance of leaving a foreign body in a patient is highest in the obese patient, the emergency case with high blood loss, and when there is a radical change in the surgery process / strategy. There is no excuse for a never event.”
How has the EMR affected communication and patient safety?
LDB: “While the EMR could be a solution, in its current state, it is not. We should have a mandate where all health care records should communicate with each other. The EMR should assist us with evaluating quality metrics. If I could design the ultimate EMR, I would design one that interfaces with all records and provides appropriate benchmarks with good quality metrics”.
SO, why do we not have this type of EMR after all this time?
LDB: “It’s expensive! We need the government to mandate that changes be made. We need to ensure that EMR’s are a part of an integrated system that communicates with everyone and provides necessary data.”
Do you believe we can strive for zero events and not paralyze our medical system? Is focusing on the specific "Never Events" and not focusing on building a safety culture detrimental?
LDB: “This environment is simply too complex to avoid ANY harm, but there is nothing wrong with this as a global mission. We must remember that we cannot avoid all complications. However, we should never have those Never Events- wrong site, wrong side, wrong patient etc. We simply cannot allow that to happen to our patients“
How do you and your organization catalyze a culture of safety at your institution?
LDB: "A culture of safety is discussed at every M & M, at every patient's bedside in all discussions about patients, on daily rounds, with the intent that no one forgets that that is always our goal."
In multiple studies, surgeons, anesthesia and critical care providers seem to be the most resistant towards patient safety checklist initiatives, so why can’t we simply step in and help fix the problem rather than constantly argue about it?
LDB: “Surgeons must remember that a culture of safety was created by surgeons long ago. Surgeons have handed that responsibility over to others and need to return to those principles. There is a consequence of being an outlier. Everyone knows there are three principles surgeons must live by: 1. clinical excellence and 2. solid education 3. good stewardship of resources, which includes effective utilization of resources in order to enhance quality care and patient safety.“
1. Fabri PJ, Zayas-Castro JL. Human error, emergency communication and system that underlies surgical complications. Surgery. 2008;144(4):557-565.
2. Helmreich RL, Shepherd HG. Team Performance in the Operating Room. In: Bogner MS, ed. Human Error in Medicine. Hillside, NJ: Erlbaum, 1994:225-253.