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Years after “To Err is Human” report, studies show marginal improvement
Failure to improve working environments for nurses poses a threat to patient safety, a speaker said at a panel discussion hosted by Health Affairs.
In addition, clinician delays in recognizing emerging complications, and communicating concerns effectively with other medical staff, can increase postsurgical mortality, explained another presenter at the briefing Tuesday, which explored progress in patient safety since the 1999 release of the landmark report “To Err is Human: Building a Safer Health System” by the Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine).
According to the report, 44,000 to 98,000 deaths each year result from medical errors.
“Everyone agrees we haven’t made as much progress as we’d like to make [with reducing medical errors], and the improvements have been uneven,” said Linda Aiken, PhD, RN, professor and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania in Philadelphia.
In a recent Health Affairs study, Aiken and colleagues assessed safety at 535 hospitals in four large states during two time points between 2005 and 2016, and reported that the results were “disappointing.” Only 21% of the hospitals showed “sizeable improvements” in “work environment scores” while 7% saw their scores worsen, Aiken said.
Another 71% of hospitals “basically remained the same,” she said.
Aiken also reported a similar lack of improvement in patient safety measures at hospitals that showed little improvement in their work environment. In the study, about 30% of nurses graded their own hospitals “unfavorably” on measures of patient safety and infection prevention and about 31% of nurses had high scores on the Maslach Burnout Inventory.
Aiken pointed out that “To Err is Human” specifically identified “transforming the work environment of nurses” as an evidence-based strategy to improve patient safety and highlighted the need for “staffing adequacy,” as well as environments that enable nurses to conduct effective “patient surveillance and timely intervention[s].”
And despite the “blame-free culture” espoused by the 1999 report, which stressed that errors are due to problems with systems not individuals, 50% of the nurses in the study by Aiken’s group reported that they believed their errors would be held against them, she said.
Aiken said the recommendation for how to fix the situation hasn’t changed since it was outlined in the 1999 report — “identify safe nurse staffing and supportive work environments as patient safety interventions.”
In another Health Affairs study, Margaret Smith, MD, of the University of Michigan Medical School in Ann Arbor, and colleagues examined the interpersonal and organizational factors that may increase the chance of “failure to rescue,” or deaths following a major surgical complication.
“We decided to take a slightly different view and look at interpersonal, organizational dynamics and their relationship with rescue,” she explained at the Tuesday panel.
Recent studies have explored targets for interventions that could improve rescue, and focused on resource-heavy solutions, such as increasing ICU staff or improving nurse-patient ratios. While important, these factors only account for a proportion of the variation seen in rescue rates among hospitals, Smith noted.
The typical course of events is an operation, followed by a seminal complication, then a domino effect of other complications, which ultimately end in a patient’s death, she added.
Smith’s group conducted 50 semi-structured interviews at five hospitals across Michigan with a range of providers (surgeons, nurses, respiratory therapists), and asked what they felt were the greatest contributors to effective rescue. The study was done from July to December 2016.
After recording and transcribing each 30-60 minute interview, Smith and colleagues identified five core elements as being part of the “successful rescue” of surgical patients:
- Teamwork: working well together in moments of crisis
- Action taking: responding swiftly after identifying a complication
- Psychological safety: ability of all clinicians to feel comfortable expressing their concerns regardless of where they fit in the clinical hierarchy
- Recognition of complications
The interviewed clinicians said they generally felt they performed well on the first three measures, but said early recognition of complications and effective communication were areas that needed improvement, Smith stated.
For example, attending surgeons said they did not think complications were spotted early enough. “When we’re talking about early recognition, people have this kind of clinical hunch [that] ‘something’s wrong’… [and] how that’s communicated is often very poor,” Smith said.
The challenge is how to communicate these “hunches” in a way that everyone understands them and ways that trigger actionable steps, she added.
In terms of communication, a senior nurse reported that when more providers cared for a single patient, it was more challenging to pass information along, or have information miscommunicated or misinterpreted.
Smith recommended that hospitals focus upstream of these potential crises by providing all clinicians, regardless of their experience, with the tools to know when a patient is deviating from a normal trajectory.
Her group also stressed the need for more effective language in communicating concerns.
“We need to ‘tool and task’ these providers with the skill-set to work on these multidisciplinary teams to communicate and identify developing complications,” she said.
Smith said her group is developing pilot programs to help clinicians recognize when patients are deviating from a traditional course.
If a patient completes a procedure without a complication, certain daily benchmarks should be expected. These benchmarks would be given to junior nurses and night staff, so that even without years of experience, they can recognize when a patient is not on track, Smith said.
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