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Oct 17

It seemed like just another twice weekly visit to the radiology clinic that summer afternoon.  


This wasn't Dad's first visit to the clinic, but rather the third in what had become part of his new treatment regimen in his battle with lung cancer. My dad had quit smoking almost 10 years before, but the many years he smoked during his 20-plus years of service in the U.S. Navy, including tours of duty in Vietnam, had most likely been the cause of his cancer. 


When Dad came out of the interventional radiology treatment room, he looked troubled and confused. I tossed the magazine aside in the waiting room and stood up as he approached. 

 

"Son," he said, “they did something wrong to me. I could feel it-- something 'popped' during the radiation.” I could tell he was scared.  


"Tell me what happened,” I said.  "Let's just get out of here and I'll tell you," he said, as others in the waiting room were now looking up from their magazines with curiosity. 


When we got in the car, Dad began to retell the experience, including the reaction of the technician during the event and the rush to end the session abruptly without any explanation of the unusual sensation he had experienced. When we arrived home, we shared the story with my mom and we all tried to make sense of what happened and what we should do next. We wanted answers, but the clinic was closed for the weekend, and the answering service at Dad's oncology practice informed us that the doctor was away on vacation and would not return for a week.  "You should call back next week," said the operator, without even a sense of urgency or concern after I had explained the reason for my call. 


On Monday, I called the radiology clinic and asked to speak to someone in charge to get some information about what had happened. But I was told that they could not discuss the matter on the phone.  The office manager said my Dad would need to speak directly with one of the radiation oncologists in the office.  Dad wasn't going anywhere given the worse-than-normal radiation sickness.


We were able to see the oncologist a week later. She reviewed documents from the radiology clinic reports and completed a cursory exam of my father.  She sat down at the foot of the treatment table and said, "Well, Ted, you've gotten more time than most," referring to the last 16 months since a routine chest x-ray showed a small mass in the lower right lobe, a pneumonectomy to remove Dad's right lung and several rounds of chemo, not to mention the radiation therapy.  "There's nothing more we can do for you, except to prepare and pray."  


My dad was stoic. My mom wept quietly to herself, and I was still focused on the cause of the radiation incident.  


Three weeks later, my dad died.


We all grieve differently. I had to make sense of what had happened at the radiology clinic. I had been an aircraft accident investigator in the U.S. Navy with extensive experience in root cause analysis.  My goal was to understand what had happened, why it had happened, and how we could keep it from happening to someone else.  


As an airline pilot for 20+ years and an aviation safety expert, this seemed to me to be a safety problem that needed to be addressed.  I wasn’t interested in legal action; I was interested in the truth.  What I would find out about the nature and extent of deadly errors in healthcare would lead me on a journey to improve patient safety across the globe since my dad’s passing in 2002. 


In a 2000 report from the Institute of Medicine called To Err is Human, researchers reported that as many as 98,000 people die in the U.S. each year due to preventable medical errors, such as the radiation event my dad suffered in 2002.  When I compare that number to aviation, it is equivalent to a Boeing 777 crashing each and every day in our country without any survivors. 


This is really the tip of the iceberg, since as few as 15 percent of adverse events are actually reported.  To add to this significant risk, over 100,000 patients each year die from preventable infections acquired during their hospital stay. One in seven of us will suffer an adverse drug reaction from a medication given while in the hospital, and 42 percent of the public report that they or someone close to them have suffered from a medical error.  


According to the Joint Commission that tracks medical errors in the U.S., nearly 70 percent of all these errors are human error due to poorly designed systems, lack of teamwork, ineffective communication and inadequate leadership. 


So what can you do to improve your safety or the safety of a loved one during their stay in a hospital or clinic? 


Over the coming months, we will focus on five proven actions that you can take to improve your safety and reduce your risk of becoming a medical error statistic.


1. Get informed – Your safety depends on having accurate information about your doctor, hospital, clinic and the associated risks related to the medical procedure or treatment they are recommending.  Ask yourself: Am I getting the standard of care I deserve?


2.  Ask Questions – Who is my nurse during this shift?  What is my main problem?  What do I need to do? Why is it important for me to do this?

3. Be Vigilant – You and your loved ones are an extra set of eyes and ears as it relates to your safe care.  Since most errors are human errors, like monitoring, it's your duty to be an active member of your own care team.


4.  Speak Up – When you experience, sense, or perceive suboptimal care, you or a family member must speak up no matter the assumptions, the time, or the condition.  Take ownership of your care: “Nothing about me, without me!”


5.  Share Information and Provide Feedback – Develop trust with your healthcare providers.  Tell them about past history and current medications.  Don’t assume anything, no matter how many times you are asked for your name or date of birth.  Fill out all surveys and provide honest feedback to healthcare professionals.  You, like me, have a chance to make the system better for the next patient.

 

Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, go to http://www.healthcareteamtraining.com/bios/stephen-powell-ms/

 

©2011 ShareWIK Media Group, LLC

 


Nov 04

Most of us do more research about the next movie will we see than we do to find the best hospital or doctor to treat our illness.  When my wife and I plan a ‘date night’ to the movies, we get online and search our local cinemas to see what’s playing. 


We look at what’s available in our immediate area and look for a title that someone has either recommended or looked appealing from a commercial or a review.  The listed movies have a star rating system either from the movie critics or the audience.  I tend to weigh my decision toward the critics and friends with similar movie tastes.  Once I click on a movie link that looks attractive, I watch the trailer or series of trailers to decide if this is the film for us.


We can compare our wants and desires with what’s playing and usually find a good match.  If not, we can expand our search to theaters located in the city where we usually find a wider variety of film genres. 


Well, reviews and ratings are just not for movies anymore because now you can choose your hospital based on performance ratings for patient safety, quality, and patient experience.  All hospitals that receive reimbursements from the Center for Medicare and Medicaid Services (CMS) are required to regularly report infections rates, complication rates, patient satisfaction and other quality measures.  


Consumers can access this information online at Hospital Compare.  When you click on the site, you will be given choices just like the movie listings. First, enter your zip code or your city and state where you live. Next, you can either select a General search or a specific condition or surgical procedure.  Then, click Find Hospitals.


If you’re located in a metropolitan area, you will have a large list of facilities to evaluate; if you’re in a rural area, you may need to expand your search area.  Select the hospitals you wish to compare by checking the boxes next to each hospital up to a maximum of three at a time then click on Compare. This allows you to do a side-by-side comparison. 


Scroll down to view and select various performance measures you wish to evaluate. Start with the tab on the left labeled ‘Survey of Patients Hospital Experience’ to see how other patients have rated the hospitals.  Other patient safety and quality measures can also be compared. 


Instead of trying to fully understand the various measures, you should focus on the difference among hospitals. Hospitals that are performing ‘worse than the U.S. national rate’ should be scrutinized more closely than hospitals with ‘better than the U.S. national rate.’


Becoming informed about the safety standards, care experience and quality measures at hospitals in your local area have become easier to access and compare.  If your physician only admits to a hospital that is performing significantly worse than the U.S. national average, you may want to consider another physician.  Remember, your safety or the safety of your loved one is worth the search. 


Oh, I forgot, enjoy the movie!

 

Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, go to http://www.healthcareteamtraining.com/bios/stephen-powell-ms/ 

Read other columns by Steve Powell here

©2011 ShareWIK Media Group, LLC

 

 

 

Dec 01

Did you ever wonder why we have so many automatic reminders, alerts, alarms and monitoring systems on everything from our microwave to our smart phone?  


Because we humans are famous for forgetting to do things, even routine things like turning off the oven or returning a rental movie.  The most common reasons are distractions, interruptions, and multi-tasking.  Now, you can see why we need all those reminders.  I have an additional back-up memory system, my wife.  She is my team member in life; she ‘has my back’.  She anticipates that I’ll forget to turn off the oven because I have before.  Why? Because I’m distracted by the cinnamon rolls. 


The nurses, doctors and staff that take care of us when we are sick are prone to the same kind of memory failures but when they forget, the consequences can be much higher than a rental movie late fee.  No healthcare professional goes to the office, clinic, nursing care facility or hospital with the intent to harm a patient, but we know harm occurs each and every day in our healthcare system. 


Up to 100,000 deaths every year in the U.S. alone due to medical errors.  One in seven patients will suffer a medication error during their hospital stay, and 24 patients die every hour from sepsis, a treatable infection that is often acquired while in the hospital.  One study showed that 35 percent of physicians reported that a family member suffered a medical error while, in the same study 42 percent of the public reported that a family member suffered a medical error.


How can we as patients, friends and family members act as that extra set of eyes and ears for our healthcare provider (doctor, nurse, or staff member)?  We can ‘watch their back’!  We can act as safety monitors of our own care.  


Here are some ways we can help our providers:


1.    Medications – you can write down all medications including any drug allergies and bring the list with you to every appointment or hospital stay.  Ask what medication you are being given and if that medication will react negatively with other medications or supplements on your list.


2.    2.   Hand Hygiene – make sure you monitor your healthcare providers to ensure that they are washing their hands before they treat you. Make sure you have some hand sanitizer for you and your visitors during your hospital stay.


3.    3.   CUS – don’t use inappropriate language instead the ‘C’ stands for concern, ‘U’ stands for uncomfortable, and the ‘S’ stands for scared; don’t hesitate letting your healthcare provider know that you are concerned about any action, behavior or condition.  If you are uncomfortable for any reason with your care or care team, speak up. If you are scared, get the attention of the nurse or doctor in-charge and share your fears.


Remember, even with all their excellent training and extensive experience, our healthcare providers are human and prone to the same mistakes, lapses and errors as their patients.  Be vigilant, ‘watch their backs’, your safety as a patient depends on it!


Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, go to http://www.healthcareteamtraining.com/bios/stephen-powell-ms/

 

Read other columns by Steve Powell here

©2011 ShareWIK Media Group, LLC

 

 

Dec 12

Two Decembers ago, my mother went to the hospital for what she anticipated would be a routine colonoscopy.  In the process of removing some polyps with a laser, the doctor inadvertently burned a small portion of her colon wall.  Unfortunately, he didn’t realize what had happened at the time, and she was sent home.  When she woke up the next morning, she was in excruciating pain and went to the emergency room at her small community hospital.


Initially, there was a great deal of uncertainty about what was happening.  The doctors detected a raging infection, which came very close to perforating her bowel wall.  At first, they thought that they could treat the infection with intravenous antibiotics and a short stay in the hospital. 


When my mother resumed eating food, however, the infection returned with a vengeance.  The local physician urged her to agree to surgery to remove her colon.  Ultimately, she insisted on being transported to a larger hospital where her main gastrointerologist worked.  There, the physicians inserted a drain in her abdomen and treated the infection.  Miraculously, they were able to avoid surgery and save her colon.  With a lot of determination on her part, she was able to leave the hospital on Christmas Eve.


Now, two years have passed, and we can talk about that dark time as a bad memory rather than a living nightmare.  My mother recalls how depressing it was to spend the Advent season in the hospital.  In addition to the pain and physical discomfort of staying in the hospital for weeks, she worried about her medical prospects and the uncertainty of not knowing how long she would remain in the hospital. On top of that, she worried about how she had no time to prepare for Christmas.  Who would purchase the gifts or make her special chocolate fudge?  Sometimes, it’s funny what we worry about at a time like that.


More than anything though, she remembers that it was a very lonely Christmastime.  While my aunt visited her in the hospital every day and my father checked on her after work in the evenings, the nights in the hospital were long.  The 12-hour stretch from 9 o’clock in the evening until 9 o’clock the next morning wore on her.  There are only so many holiday Hallmark movies that one person can stomach in a day. It’s very hard to be alone in the hospital, removed and isolated from day to day life.  No holiday parties, festive treats or kisses under the mistletoe.


I suppose that part of what makes spending the holidays in the hospital very difficult is our collective expectations.  We have so many ideas about whom we should be with and how we should celebrate. More often than not, reality doesn’t coincide with those expectations. Certainly not when you’re in the hospital.


Given that the anniversary of my mother’s hospital stay and Christmas coincide, I want to be thankful for her health and my health this year.  I would also like to be mindful of those who are ill this holiday season. 


Maybe you know someone who is housebound, in the hospital, or struggling with an illness.  Try to take the time to comfort them and spread a little holiday cheer.  Perhaps most importantly, try to focus on what you do have rather than what you don’t have this holiday season.

 

A former Duke-educated attorney, Jena Reger shares her roller coaster ride with Crohn's disease.  She hangs on with irreverence, compassion, and a lot of hope. She is a regular columnist for  ShareWiK.com.  You can visit her on the Web at www.jenareger.com.

 

 Read other Jen Reger columns here

 

©2011 ShareWIK Media Group, LLC

 

Dec 30

In football, the handoff is a critical exchange of the ball between players. Timing is crucial and practice is essential to ensure fumbles don’t occur.  Even with long hours of practice and repetition, even the most skilled teams and players fumble. This is human error and there are multiple reasons why the fumble occurs.  The most common reason may be a 300-pound defensive lineman who hits like a freight train.


The handoff in healthcare settings occurs between providers (doctors, nurses, nursing aides and technicians) and the ‘ball,’  which is the patient and their unique information.  A fumble of patient information can have serious consequences. 


In a 2011 national survey on patient safety, over 55 percent of more than 470,000 healthcare providers reported negative perceptions of patient handoffs in their hospitals. Only one dimension of patient safety within the survey was more negatively reported than handoffs by healthcare professionals.


This should concern you as a patient or family member because it is a great concern of those professionals providing you care.  What if this actual case were your infant daughter?


A 3-month-old baby girl was admitted with a respiratory infection to a pediatric hospital unit. Although she was initially stable, her breathing soon became labored. Providers determined that she would benefit from a higher level of care in the intensive care unit and initiated the transfer process.


This transfer happened to coincide with a (day-to-night) shift change for both the nursing staff and the physicians involved. The off-going nurse assumed the transfer would take place immediately and signed out her patients to the next nurse before the patient was physically moved. The outgoing physician sent a text message to his incoming colleague with similar information.


Approximately 45 minutes later, the unit clerk called the infant’s bedside nurse to report that the infant’s parents believed their child was in significant distress. The nurse was surprised the patient had not yet been transferred and, after an initial evaluation, immediately called the hospital emergency response team.


Scary, but this sort of fumble happens more often than you’d expect with poor handoffs as a leading cause of accidental deaths and severe injuries in hospitals. In the case of the three-month-old baby girl, the providers made assumptions about the urgency of the baby’s deteriorating condition.


The fact that the handoff order came during a scheduled shift change meant that team members were managing a regular ‘workload spike’ dealing with the transfer of information on multiple patients at the same time. Talk about multi-tasking!


Communication that is face-to-face is preferred during handoffs since almost 60 percent of communication effectiveness is non-verbal.  Phone calls, text messages, and even your medical record are not as effective as two-way communication. Many hospitals are now performing patient handoffs bedside in front of the patient and family members –if privacy policies permit – to improve the transfer of information. 


So, how can you as a patient or family member get on the team instead of just being the ball?


For one, you can react as this family did – be assertive and ensure your concern is heard and acted upon by your healthcare providers.  Additionally, you too can anticipate the workload spikes that occur during shift changes in hospital units.  Have a family member or friend present at shift changes when possible.


You can also ask your nurses to conduct their handoff at the bedside so you could ensure that all pertinent information is accurate and shared.  Always make sure that your incoming providers are aware of key information, ask questions if you need clarification, share personal information like drug allergies and remember, when it comes to your healthcare; ‘nothing about you without you’!


Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, go to http://www.healthcareteamtraining.com/bios/stephen-powell-ms/ 


Read other columns by Steve Powell here.   


©2012 ShareWIK Media Group, LLC

Feb 22

Have you ever considered that the experience of being a patient in a hospital may be similar to other institutional experiences? 


Where else do you go where they take your clothes from you? Where else are you identified by a number? Where else is every action based on an order?Where else do they tell you when and what to eat? Where else are a series of rooms known as wards? Where else are you confined to a given area of the institution?


Well, by now you guessed it – a prison or jail is the answer!  Although I’ve never been incarcerated, thankfully, most prisoners want one thing more than anything else and that is to get out!  That is another common desire among patients as well.  Getting out of the hospital means you’re hopefully well enough to convalesce in another care setting or in your own home.


The process for getting your release is known as discharge.  As much as you want to get released, hospitals also want you to go home (nothing personal, of course).  Every day you stay in the hospital longer than the predicted stay for your procedure or condition costs the healthcare system more and most importantly, longer lengths of stay increase your chances of contracting a hospital-acquired infection like staph or MRSA.


Unfortunately, many discharges don’t go well in our healthcare system.  


One study showed that as many as 4.4 million hospital stays are the result of discharged patients who were readmitted.  This cost of preventable readmissions is estimated to cost our healthcare system more than $30 billion (yes, with a B) each year.  Many of these readmissions are linked to the discharge process.


Some patient conditions are more likely to be readmitted with 30 days of being discharged based on historical data:


¥ Heart attack: 19.9%


¥ Heart failure: 24.7%


¥ Pneumonia 18.3%


¥ Circulatory system disorders: 10.4%


¥ Mental health: 11.8%


¥ Digestive disorders: 10.3%


¥ Alcohol/substance abuse: 13.0%


So how can you make sure that you don’t end up back in the ‘Big House’?  


The National Patient Safety Foundation provides a tool for patients and families to use that can improve your discharge experience and improve your odds of staying healthy and out of the hospital.


1. Understand your discharge instructions


2. Know my diagnosis or condition


3. Follow up with my care


4. Protect myself from infections


5. Manage my medications


Having a capable loved one, close friend or patient advocate to assist you after discharge has been proven to reduce preventable readmissions.  Remember, you’re just on ‘parole’ until you’re fully recovered, so pay close attention to these important actions to keep you safe from harm.


Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, go to http://www.healthcareteamtraining.com/bios/stephen-powell-ms/ 

 

Read other columns by Steve Powell here.   

 

©2012 ShareWIK Media Group, LLC

Jul 28

"Hello Wanda, I'm Helen. I am one of the lactation specialists here at the hospital," said a short, petite woman in her forties with flecks of silver in her black hair.


"I am here to help you anyway I can with breast feeding your baby girl," she added with a calm certainty. "Your baby will truly benefit from breast feeding and I want to make sure you know that I am here to support you until you are comfortable on your own."


How would an exchange like this make you feel if you were a first-time mom who was struggling with the entire breast feeding process so soon after giving birth after 16 hours of difficult labor?


This initial exchange is a simple yet often forgotten first impression between healthcare providers and their patients. We live in a culture where introductions are essential elements of basic etiquette, to do anything less could be considered rude or, at best, indifferent. 

Remember, what's rude out there (in social settings) is rude in here (the healthcare system).


Name activation is a personal invitation to engage, build trust, show respect and invite mutual participation. What is being planned next in the care plan is important to every patient especially as a parade of different hospital staff seems to never end and amplifies at shift changes. A seasoned nurse once told me, "most patients first want to know how much we care before they consider how much we know."


Simply put, this effective strategy for engagement is also a powerful patient safety strategy first pioneered at Florida Hospital called The Three Ws.


Who - make an introduction.

What - describe the reason for your visit or task.

Why - share why you care and why this is important to the treatment plan.


The first two are more information-based statements and may be more common even among the busiest caregivers. The last 'why' separates truly caring and empathetic providers from a robotic task-driven production model of care that may fall short of a truly excellent patient experience that is safe and patient-centered.


You, as a patient, advocate or family member, can use The Three Ws the next time you interact with your healthcare professional. If they are task-saturated, 'heads down' or impersonal, you can engage them by reversing The Three Ws process to make a simple yet essential personal connection.


Today's healthcare professionals are being asked to do more and more tasks, like computer data entry, while caring for sicker patients with nurse-to-patient ratios that are created by efficiency software programs not clinicians. These formulas rarely consider the importance of the human connection between healthcare professional and patient, producing the uncomfortable tension between efficiency and effectiveness. You are not the next 'widget' being produced in the healthcare system; you are not an outcome; you are a person who deserves Three Ws or eye contact at the very least.


One of our hospital clients has gone even further than just Three Ws. They have instituted what they call a 'no passing zone,' whereby you aren't allowed to pass anyone in the hall of the hospital without making eye contact and exchanging a simple greeting. Now that is real change, especially for a hospital located in busy New York City.


Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, click here


©2012 ShareWIK Media Group, LLC



Aug 06

There’s a great book by Fred Lee, a former Disney executive, entitled "What if Disney Ran Your Hospital?"  The book proposes that many of the principles used in the hospitality industry could be beneficial to patients or ‘guests’ in a hospital.  Many healthcare executives have successfully used this book to change the patient experience at their facilities.  When I think of Disney, I immediately think of a transforming experience when I enter its theme parks.  It’s the experience that keeps generation after generation coming back to Disney.  So, I figured that ‘an outstanding guest experience’ must be the number one goal of each and every employee at Disney.  I was wrong.  


According to Lee, although the guest experience is central to Disney’s theme park success, safety remains the number one goal of Disney!  Without safety, there is no exceptional experience.  Someone could be hurt on Space Mountain.  A child could get separated from his or her parents and snatched by a predator.  Many visitors could become sick from a lack of sanitation in the food service areas.  So, at Disney, safety is the number one goal, enabling an exceptional guest experience.  The average guest has no idea what safety precautions and practices must be executed flawlessly each and every day for Disney to achieve such an exemplary safety record.  Truly the culture at Disney is a safety culture and certainly not by accident.


So, with this same thinking in mind, I thought the number one goal of going to a hospital was to engage highly-qualified professionals who would partner with me or my family member to manage my healthcare condition.  Actually, the number one goal of the healthcare professional is to first, do no harm.  This is attributed to the Hippocratic Oath that most doctors take when they are medical students.  


What if patients and families took this same approach to their hospital experience?  First, do no harm.

  • When anyone entered your room, you would ask them to wash their hands to prevent harm from infections.  
  • You would ensure that your highest-risk conditions were known by each and every caregiver. Examples would be allergies, past complications, vertigo, literacy, language, pain, etc.
  • Before any procedure or medication administration, you would ensure that your name and date of birth were verified to ensure the ‘right’ patient, ‘right’ procedure and ‘right’ medication.
  • When you used the call button, it would be answered in a timely manner so you could safely go to the bathroom without fear of injury due to a fall.
  • When an alarm went off at your bedside, the health professionals would respond appropriately and you would understand the reason for the alarm.
  • When IV medications were started, the correct lines and pump settings would be accurately established.
  • You would ask ‘Why’ questions regularly, especially related to changes in your care plan.  Why is it important for me to have this test?  Why am I taking this medicine orally?
  • You would ask that all hand-offs or handovers of care from shift-to-shift be done at your bedside so you or your family member could verify and clarify essential information.
  • At discharge, you would check-back or ‘teach-back’ the discharge instructions with your healthcare professionals to ensure that you truly understand what’s important for you to heal at home.

You, as patient and family member, can be a valuable patient safety team member so that first, no harm is assured.  Your experience of care is rooted in this foundational principle: safety first!


Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, click here.


©2012 ShareWIK Media Group, LLC


Aug 20

If you are in business, you may be familiar with the quote attributed to management guru Peter Drucker, “Culture eats strategy for breakfast.”  This saying was a wake-up call to corporate America in the 90’s; whereby in the global economy, your people (employees) and the way they treat customers will differentiate your company from your competitors. 


If you were Enron, you had a culture of greed that wasn’t sustainable.  If you had a culture of risk-taking and untested financial products, you could end up like Lehman Brothers.  If you had questionable safety and training practices, you wouldn’t survive a preventable accident like Colgan Air near Buffalo, N.Y. in 2009.  Maybe there is something to this dynamic known as culture?  Maybe the healthcare industry needs a new culture instead of just more strategies.

Culture has simply been described as ‘the way we do things.’  Think Wal-Mart versus Target.  Both are considered ‘Big Box’ stores but the similarity in cultures might end there.  How is the experience different? What are your expectations when you visit?  What are the key factors in your decision to shop at one retailer over the other?  The corporate culture drives your experience from the look and feel of the stores all the way to the interaction between you and the store greeter.  If I say Google and Apple, you may immediately have an opinion of the culture at each.  Young kids in blue jeans with laptops and iPads attached at the hip comes to mind.  Creativity, innovation, branding and service may be other key insights from these respected and highly successful companies.  


How about in healthcare?  What sort of reaction do you get related to these cultural traits when you think of national, state or local health care institutions?  Maybe culture isn’t the first thing that comes to your mind.  Maybe it’s a billboard from your local hospital touting a new national ranking like U.S. News and World Report and Consumer Reports.  What do these rankings tell us about culture? The answer is not clear.  


Like most publicly reported patient safety and quality data, matching apples to apples isn’t that easy.  Safety culture isn’t currently publicly reported by institutions, although the Agency for Healthcare Research and Quality (AHRQ) has collected voluntary safety culture survey responses from 567,703 healthcare staff in over 1,100 hospitals in the U.S. and creates publicly available reports on the results.1


If Drucker were right about culture then the more positive the culture, the better our healthcare system would perform.  


In the 2012 AHRQ safety culture results, only 30 percent of respondents (physicians, nurses, staff and leaders) gave their organization a patient safety grade of excellent.1  When it comes to your healthcare, patients and families expect excellence and unfortunately you as a patient and consumer have no way of knowing where to find those excellent cultures.  


Maybe in the future, patients and families will get to ‘weigh-in’ on the safety culture of their local healthcare facilities or maybe they already are through patient satisfaction surveys; some reports indicate strong correlations.2


Sources

  1. Sorra, J., Famolaro, T., Dyer, N., et al. Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report. Prepared by Westat, Rockville, MD, under Contract No. HHSA 290200710024C. AHRQ Publication No. 12-0017, January 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/hospsurvey12/index.html
  2. Wolosin, R. J. (2007, November 14). Hospital-level relationship between safety culture and service quality. Patient Safety & Quality Healthcare.



Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, click here


©2012 ShareWIK Media Group, LLC



Sep 08

Wanda had just returned from another funeral.  She was on the committee at her church that prepared meals for the families of those who passed.  She was a great cook who enjoyed giving back to her community.  She’ll never forget the compassion shown to her when her husband Charles passed several years ago.  


Today, she felt more tired than normal.  In fact, she was exhausted. Climbing the steps to her front door seemed like climbing Mount Everest. She felt almost out of breath by the third step.

She sat down once inside, still unable to catch her breath.  She decided to call 911 and her son Jerome. Both responded that they were minutes away.  Once she arrived at the local emergency room, Wanda was feeling a little better; maybe it was the oxygen the paramedics had placed on her face.  Dr. Rajiv Singh, the ER physician, took Wanda’s history and learned that she was on medication for diabetes and high blood pressure.  She had tried to lose some of the weight that contributed to her diabetes but was having difficulty sticking to the diet her doctor had recommended. Dr. Singh told Wanda that he would need to take some blood and perform a series of other tests on her heart.  


Once the blood work and test results came back, Dr. Singh told Wanda and Jerome, who by now was at the hospital, that she was having irregular heartbeats that would need to be treated with medication.  Dr. Singh went on to say that he was more concerned about her diabetes and had asked for a consult, which would take another hour to complete.  Jerome needed to check-in with his office and was gone for about a hour.  During that time, Dr. Singh returned and said he had good news and bad news.  The good news was she could go home.  The bad news was she would need to begin dialysis for her kidneys related to the increased complications from her diabetes.  He explained the situation but Wanda seemed confused and unable to process “dialysis.” 


The ER nurse brought in all of the discharge paperwork including all prescriptions and instructions for contacting the dialysis clinic in their community for the treatments.  The nurse asked Wanda if she understood and she hesitantly shook her head still in a ‘fog’ as Jerome returned.  The packet of papers was placed on Wanda’s lap as the transport technician arrived with the wheelchair.  Jerome returned and found out the good news that his mom was ready to go home.


He opened the thick packet when they arrived home and saw the prescriptions for the heart medications and called his wife to come by and take them to the local pharmacy to be filled.  The other papers in the packet seemed like general discharge information and Jerome was late getting back to work for an important afternoon meeting and rushed out when his wife arrived.

A nurse from the hospital called a few days later and asked Wanda how she was feeling and if she had gotten her prescriptions filled and her appointment made with dialysis.  She wasn’t sure who was calling and said she did get her medicine and she assumed her son had taken care of the other appointments.  The nurse said she was glad to hear that, wished her well and hung up the phone.  


Jerome noticed by the weekend that his mother wasn’t getting any better and took her back to the ER.  As luck would have it, Dr. Singh was back on duty covering the weekend schedule.  He was surprised to see Wanda and Jerome.  He asked Jerome about the dialysis and Jerome seemed surprised.  “What dialysis?” he said.  


The doctor discovered that Jerome was never told about the dialysis and Wanda assumed Jerome would take care of all the arrangements since she was feeling so poorly.  Dr. Singh ensured Wanda that he would not make the same assumptions about the discharge this time and started to go through the materials one sheet at a time, giving Wanda and Jerome ample time for questions while having them repeat important instructions.



Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, click here.



©2012 ShareWIK Media Group, LLC


Oct 17

My wife and I recently went shopping at a popular furniture warehouse store near our home.  We were looking for kitchen chairs and immediately spotted a nice black chair that matched our table and was comfortable especially when we added the $6.95 cushion.  I dutifully read the product number off the chair as my wife transcribed.  She checked back the number as she wrote it and we made our way towards the warehouse to pick up our chairs by matching product numbers.  What could go wrong?  We selected the eight boxes with our chairs inside and completed our trip through the checkout lane.


We were all set to build our chairs using the enclosed directions and handy tools just for our project; but one thing was wrong. When we opened the first box, the chair inside was a natural pine finish not the black chairs that would match our kitchen table.  How could this have happened?  


We double-checked the product number, found the boxes and followed the system but we didn’t have a successful outcome.  Well, back to the store to return our purchase and find the black chairs.  We found the problem right away. Someone had placed the wrong tag on the black chair in the showroom.  


The clerk at the return desk was kind and apologetic.  In a few short minutes we had the black chairs and we were on our way back on our 45-minute journey through rush hour traffic.  We used about $20 in extra fuel, not to mention an extra one-and-a-half hours of our time.  Maybe we should have asked the store to compensate us for our extra fuel and time?  After all, wasn’t it their mistake?  Maybe a new returns policy was needed.


On Oct. 1, 2012, a new part of the Accountable Care Act (Healthcare Reform) went into effect dealing with hospital readmissions for certain conditions within 30 days of discharge.  Nearly one in five Medicare patients return to the hospital within a month of discharge, which in 2010 cost the government an extra $17.5 billion.  


Medicare has estimated it will recoup about $280 million from hospitals where it determined too many heart attack, heart failure or pneumonia patients returned within 30 days (Rau, 2012)*.  The law is designed to incentivize hospitals to improve quality.


You (as a patient or patient advocate) can help prevent unwanted returns to the hospital and reduce preventable readmissions by using a simple, yet comprehensive tool or checklist developed by the National Patient Safety Foundation.  The post-discharge tool includes the following helpful tips to avoid being returned to the hospital for your previously admitted condition:

  1. Understand your discharge instructions.
  2. Know your diagnosis or medical condition that you suffer from.
  3. Follow-up with your care with your healthcare provider.
  4. Protect yourself from infection.
  5. Manage all your medications.

Download a copy of this valuable tool and share it with a family member, loved one or friend.

Your return trip to the hospital will not be the minor inconvenience of returning chairs.  Instead, your readmission will mean more risk, more treatment and more costs.  With hospital readmissions, more is less when it comes to patient safety and quality of care.  


You are an integral part of preventing readmissions.  Let’s make sure returns are minimized for your health and the health of your loved ones.


*Rau, J. (October, 2012). Medicare Revises Hospitals' Readmissions Penalties.  Kaiser Health News. Accessed at http://www.kaiserhealthnews.org/Stories/2012/October/03/medicare-revises-hospitals-readmissions-penalties.aspx



Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, click here. Follow Steve on twitter @S_SPowell


Read more columns by Steve Powell here.


©2012 ShareWIK Media Group, LLC



 

Oct 29

The other day, as I sat next to my niece’s bedside at a local children’s hospital, I was reminded of how much I admire people who become nurses. Like most of the nurses there, the nurse on duty was young. She’d only been employed there for 18 months, but it was obvious she loved her job.


And my niece loved her. The nurse was totally at her beck and call. “Do you want another ginger ale?” “How about some salt crackers?”


Memories of many of my favorite nurse stories flooded my mind. I remember after my hysterectomy - my first surgery after my cancer diagnosis - I was in the hospital nearly a week. It was a Sunday night and my body had accomplished all of the doctor’s conditions for me finally going home. I wanted out of there.


But there was a hitch. I do not remember all of the details, but I know it had something to do with me getting a prescription that I would need for the next week. My miracle nurse, as I called her, was a young woman from Malawi. She was my protector. She talked to my doctor’s office and if I promised to get to the office the next day to pick up the prescription, they would let me go home. I was a happy camper.


My last surgery, in February, was for an intestinal blockage. I came through the surgery relatively well, and then one of my nurses explained that my doctor had ordered something called a PICC line so that I could receive nutrition intravenously. A PICC line is a long, slender, flexible tube that is inserted into a vein, usually in the upper arm. 


I already had an IV for my liquids and antibiotics. This was going to mean another insertion, and I did not want it. I have very small veins and getting IVs and other “insertions” is always painful and difficult. Oftentimes, the nurses were unable to get it right the first time. And afterwards, I’d have black and blue marks on my arms and hands.


I talked to one of my nurses about the order and she assured me that it was totally up to me. I could make the decision whether to have the PICC line or not. I did not have to receive the line just because my doctor ordered it.


I saw no reason for it. There was no indication that my nutritional level was unhealthy. So I said no. The doctor on call from my oncologist’s office was shocked that I didn’t just offer up my arm. 


I learned a lesson from that nurse: I could make decisions for myself despite being under a doctor’s care in a hospital.


I have had so many good experiences with nurses. I think they are heroic. They fulfill needs that most of us can’t imagine doing. They perform miracles. And I believe it takes a special person to become a nurse.

One of those special people who always knew that was her chosen profession is my best friend from high school. Though we have rarely seen each other in the 42 years since we graduated, I know Paula is always there for me with her gentleness and compassionate knowledge. She was born to be a nurse and there are thousands of lucky patients who have benefitted.


Jan Jaben-Eilon is a long-time journalist who has written for The New York Times, Business Week, the International Herald Tribune, the Jerusalem Report and Womenetics. She was a founding reporter for the Atlanta Business Chronicle and was international editor for Advertising Age before she fulfilled a lifelong dream of moving to Israel. Jan and her Jerusalem-born husband have an apartment in that city, but live in Atlanta.

 

In November 2006, she was diagnosed with late stage ovarian cancer and has kept a blog on her cancer journey since December of that year. Follow her on Twitter @janjabeneilon


Read more columns by Jan Jaben Eilon here



©2012 ShareWIK Media Group, LLC


Nov 12

My mom called me at an odd hour during her recent visit with friends on the west coast.  Maybe she forgot about the three-hour time difference.  She was 79 after all and has forgotten more little things lately.  Instead, she apologized right away saying she was sorry to be calling so late but she wanted me to know that something had happened during her visit.  


With those words, I braced for bad news as she said, “I’m at the emergency room, don’t worry.” Isn’t that an oxymoron?  Emergency room and “don’t worry” should not be used in the same sentence.  “What happened?” I asked.  My mom calmly began explaining that she fell and broke her wrist and was getting a cast.  She had fallen while dancing with friends at a popular veterans club for seniors.  I could almost see the sheepish grin on my mother’s face as she spoke.  My wife rolled over in bed to hear the story and was glad she was going to be okay, saying, “I hope we’re still dancing at 79!”


Falls, especially in the senior community, are a common occurrence.  Falls in hospitals, long-term care and rehabilitation facilities are also common and can cause severe injuries.  One study suggests that as many as one million patient falls occur during hospitalization each year within the U.S., resulting in 90,000 serious injuries and up to 11,000 preventable deaths (Currie, 2008).  Although less than one percent of hospital patients suffer a fall during hospitalization, one can see that being 99.4 percent reliable as it relates to falls is not good enough to prevent significant patient harm. 


Most falls occur when a patient tries to go to the bathroom, especially during the night (Currie, 2008).  Other falls occur when a patient is trying to reach for something and ends up falling out of bed.  Hospitals have tried many interventions, including non-skid socks to prevent slips, more advanced bed rails, more sophisticated call systems, lighted pathway systems in the hospital rooms, better hand holds in bathrooms, shower entries without thresholds, and bed alarm systems.  


Nurses routinely perform a falls assessment for each patient in their unit to better predict a patient’s likelihood for exiting the bed without supervision or assistance.  Patients at particular risk for unassisted bed exits include agitated patients, patients with delirium and patients taking narcotic medications (Currie, 2008).  When a patient is at-risk for falling, a nurse may decide to use a bed alarm to provide an early warning.


Although this sounds like a potential fix to the falls problem for high-risk patients, false alarm rates can be as high as 90 percent, causing many nurses to ignore the alarm due to a phenomenon known as alarm fatigue (Hubbartt, 2011).  Alarm fatigue occurs when there are so many alarms going off (especially related to vital signs) that hospital staff members process the alarms as ‘white noise’ or background noise.  This is why, when a pump finishes infusing IV medication in your arm and the alarm goes off in the hospital, it can be many minutes before someone comes to cancel the alarm.  To the patient or family member, the alarm means something is wrong; in this case, it means something is normal; the medication infusion is complete.


You as a patient or family member can help alert your nurse to important alarms through your call system.  Additionally, you can ask your nurse about alarms that are part of your care and treatment so you are more aware of routine versus serious alarms.  


When (not if) your nurse suffers from alarm fatigue, a friend or family member may have to go to the nurse’s station to ask for assistance to the bathroom or to get someone to cancel an unimportant alarm.  If you don’t think anyone hears you, it probably because of all that noise.  Keep trying to get your nurses attention; your safety depends on it!  


Although busy and chaotic most of the day, your hospital room is no dance floor on a Saturday night; if you fall, it could be awhile before someone notices.


Sources:


Currie, L. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Volume 1. AHRQ Publication No. 08-0043. Accessed at http://www.ahrq.gov/qual/nurseshdbk/nurseshdbk.pdf 

Hubbartt, B., Davis, S. and Kautz, D. (September/October, 2011).  Nurses’ Experiences with Bed Exit Alarms May Lead to Ambivalence About Their Effectiveness. Rehabilitation Nursing, 36, 5, pp. 196-199. Accessed at http://www.ncbi.nlm.nih.gov/pubmed/21882797 


Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, click here. Follow Steve on Twitter @S_SPowell


Read more columns by Steve Powell here.


©2012 ShareWIK Media Group, LLC

Dec 11


I was recently working with a team of healthcare leaders from a large U.S. hospital who were investigating an accidental patient death due to a medication error.  This session was somber and serious as the team poured over the facts of the case and followed an investigative process known as root cause analysis. In hindsight, the causes of this terrible tragedy seemed all too clear.  


A shift change was in progress with two very sick elderly patients in a critical care unit.  Intravenous medications had been ordered for both patients and were on their way from the pharmacy.  The off-going nurse, Dianne, was finishing some last-minute charting on Mary, an 83-year-old grandmother of 12 who was finally stable enough to move from the Intensive Care Unit (ICU) to a bed on the ward.  She was still very sick and would need to stay for at least another week as her recovery continued. 


The second patient, Ned, was another story. He wasn’t leaving the ICU and was instead in the final stages of congestive heart failure. Ned was in very serious condition. He needed medication just to keep his blood pressure in a stable range.  Dianne was an experienced nurse and knew how to handle all the intricacies of these two patients.  Things had been pretty chaotic around the hospital lately with all the layoffs and cost-cutting. Her nurse manager had explained at a team huddle that the hospital was seeing 20 percent fewer patients than normal although you sure couldn’t tell it by the volume in the ICU. Several senior ICU nurses had taken an early retirement ‘package’ and the replacement nurses were on a steep learning curve.


Dianne noticed that James, one of the new ICU nurses, would be her replacement on the night shift so she decided to stay a little while past her regular end of shift to make sure the medications were properly administered.  Just as the first medication arrived, she received a phone call from her sister who was in tears.  Dianne was getting married in two days and her sister was to be her maid of honor.  Unfortunately, her sister had developed the flu and was too sick to travel to the wedding.  Dianne’s mind began to race as the wedding seemed to be unraveling with each new word from the call.  


Dianne told her sister that she was at work and would call her back once she got in her car for home. She then turned back to Mary, took the medication bag that had just arrived from the pharmacy, hanging the medication and starting the infusion pump.  She did the same for Ned.  James spoke to Dianne during the patient handover but could tell she was pre-occupied and had even been crying but didn’t want to pry.


James first heard the alarms when Mary’s blood pressure began to rise while at the same time Ned’s blood pressure alarm sounded as his rate began to drop.  It was only after all attempts to revive Mary had failed that James noticed the mix up in medications. Of course, Dianne was devastated when she learned of her mistake.  Mary’s family was grief stricken and looking for answers from the hospital.


I wondered to myself as I pondered the evidence on the table, “What would Mary say if she had survived the medication error?” 


Patient safety investigations are typically retrospective events like Mary’s fatal medication error, handled internally by the hospital. There is no independent investigation when a medical error occurs in U.S. healthcare system like the National Transportation Safety Board for airline accident investigations.  


Hospital boards and safety committees are beginning to add the patient’s perspective to their investigation deliberations by enlisting actual patient representatives from their community.  But even with this changing dynamic in our hospitals, who really speaks for the patient when a medical error occurs?


Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, click here. Follow Steve on Twitter @S_SPowell


Read more columns by Steve Powell here.


©2012 ShareWIK Media Group, LLC



Jan 04

Each year, many of us make resolutions for improvement.  


Resolutions usually fall into three categories:  What do I need to stop doing?  What do I need to start doing?  What do I need to keep doing?  


I thought I’d list a few possible resolutions you might want to adopt for your safety as a patient or for a loved one who may enter a hospital this year.


What do I need to stop doing to ensure patient safety?

  1. I need to stop being afraid to ask questions of my doctor or healthcare provider.
  2. I need to stop thinking that my healthcare providers know more about  me than I.
  3. I need to stop making the flawed assumption that my caregivers don’t make mistakes.
  4. I need to stop believing that all hospitals deliver the same quality of care.
  5. I need to ‘stop the line’ if my safety or my loved one’s safety is at risk.

What do I need to start doing to ensure patient safety?

  1. I need to start writing down my questions before I see my doctor.
  2. I need to record and share a list of all my medications including over-the-counter drugs.
  3. I need to start being a more active, engaged member of my own healthcare team.
  4. I need to start researching the quality and safety performance of my local hospital.
  5. I need to start using simple tools like ‘Speak Up’ to ensure my concerns are heard.

What do I need to keep doing?

  1. I need to keep following my hospital discharge instructions and ask questions as needed.
  2. I need to keep providing feedback to my healthcare professionals so care is improved.
  3. I need to keep educating myself on the risks of medical errors and proven solutions.
  4. I need to keep my healthcare professionals focused on me as a person not as an object.
  5. I need to keep myself as healthy as possible to avoid hospitalization and its related risks. 

Happy 2013!  Let’s make this year the year that patient safety includes the patient and family as key partners for ensuring quality care that is safe, timely, effective, efficient and patient-centric.



Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, click here. Follow Steve on Twitter @S_SPowell


Read more columns by Steve Powell here.


©2013 ShareWIK Media Group, LLC


Jan 29


My daughter lives in a neighborhood that has experienced a recent surge in crime.  She has become more aware of her surroundings and regularly uses the “buddy” system.  Every time I speak to her by phone, I remind her to stay vigilant especially late at night or when she is by herself.  Her safety depends on her vigilance.


A common definition of vigilance is “the action or state of keeping careful watch for possible danger or difficulties.”  When you are a patient or a family member of a patient, you can be an extra set of eyes and ears during your hospital stay or visit to prevent possible danger, difficulties or harm. 


You become a witness to your care; you observe how well your care team performs; you assess your personal care experience.  You also gauge your pain levels; your continued symptoms and your improvement or setbacks. We are most effective at being vigilant when we use all our senses while anticipating where and when we should pay the most attention to our situation. The following are a list of incidences that require heightened attention or vigilance to ensure inherent risks are properly managed.

  1. Administration of Medication – make sure your caregiver matches the medication label with your patient identification every time; no matter how familiar you have become with your caregiver.  If you are getting a medication for the first time, please ensure you know why. Don’t assume anyone remembers your medication allergies; remind them each time!
  2. Transitions in Care – each time a handoff or handover occurs between healthcare providers, settings or shift changes, ineffective information exchange can result in errors in your current or future plan of care.
  3. Alerts – make sure your caregivers respond to call signals in a timely manner.  The responsive of your caregiver is important to your safety. Slow responses could mean your caregiver has too many patients which is known as ‘nurse to patient’ ratio.
  4. Hand Hygiene – each time a person, provider or family member, enters your patient room or treatment area, ensure they wash their hands to prevent avoidable hospital-acquired infections. If you didn’t see them wash their hands, it’s alright to ask them.
  5. Discharge – before accepting your discharge instructions, look for clear instructions in lay terms that you and your family can understand. Make sure you know how to tell if you are not healing properly and who you can call to get questions answered no matter the hour.

You and your family members have a responsibility to actively scan and monitor the actions of those who are caring for you; especially during these critical events. Don’t make assumptions about what is known or not known about your care plan. Stay actively engaged, stay alert, and stay vigilant; your safety depends on it! 


Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, click here. Follow Steve on Twitter @S_SPowell


Read more columns by Steve Powell here.


©2013 ShareWIK Media Group, LLC


Feb 11


You push the call light on your hospital bed rail; no one answers. You push several times more; finally, a voice at the nurse’s station answers. “May I help you?” the voice says quickly. You answer, “Yes, I need help going to the bathroom.”  “OK, I will let your nurse know.”  20 minutes pass with no sign of your nurse. You eventually run out of patience as your bladder feels as if it will burst at any moment. Instead, you let your husband assist you out of bed.


In a 2012 U.S. survey of patient safety from the Agency for Healthcare Research and Quality (AHRQ), a department of Health and Human Services, over 1,128 hospitals and 567,703 hospital staff reported only a 56 percent positive perception of staffing at their hospital. Staffing survey questions measured the extent to which there are enough staff to handle the patient workload and staff work hours are appropriate to provide the best care for patients (AHRQ, 2012). This meant that 44 percent or nearly 250,000 nurses, doctors and administrators were not positive about their staffing numbers.


Insufficient staffing can lead to severe patient safety risks including patient falls, pressure ulcers or bed sores, unnecessary delays in medication administration, pain management and other failures in your treatment plans. If your medical condition is changing rapidly, delays in treatment could be lethal (Aiken, et al., 2002).  


Additionally, staffing shortages can have a long term impact on nursing performance.  In 2009, the American Nurses Association asked over 16,000 nurses about staffing shortages at their hospitals. More than 72 percent of the nurses surveyed believed they did not have sufficient staff to provide safe care at their hospital. Furthermore, 50 percent of these nurses would not feel confident having a loved one treated at their hospital due to these shortages (ANA, 2009). 


So, what’s behind the staffing numbers?


Many states require adherence to strict staffing formulas and ratios to guide sufficient resources. Others voluntarily follow staffing guidelines set by the Nursing Database of Nursing Quality Indicators (NDNQI) system for safer nurse-to-patient ratios, skill-based patient assignments and length of nursing shifts.  


While these ratios can support developing an adequate workforce, most formulas don’t account for inherent variability of individual or team performance on any given shift, patient acuity or spikes in workload. Individual fatigue, stress and poor teamwork can impact your care team effectiveness. Even though the staffing grid or formula may indicate sufficient ‘numbers’ of staff are present on any given shift, you may still not receive the care you expect.


Don’t be afraid to ask your hospital or healthcare facility about their staffing ratios and policies, number of unfilled nursing positions, number of temporary nurses, teamwork training practices, and nursing satisfaction results. The answers to these questions directly impact the quality and safety of your hospital experience of care.




References:

  1. Agency for Healthcare Research and Quality (AHRQ) (2012). Survey of Patient Safety Culture Comparative Database accessed at http://www.ahrq.gov/qual/hospsurvey12/hospsurv121.pdf
  2. Aiken, L., et al. (2002) Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Accessed at http://www.ncbi.nlm.nih.gov/pubmed/12387650.
  3. ANA Nursing Staffing Poll Results from 2009. Accessed at http://www.safestaffingsaveslives.org/WhatisANADoing/PollResults.aspx.




Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, click here. Follow Steve on Twitter @S_SPowell


Read more columns by Steve Powell here.


©2013 ShareWIK Media Group, LLC


Feb 27

A common saying among business leaders is: “You can’t manage what you can’t measure.”  This is especially true when it comes to patient safety. Self-reporting is an essential component of measuring patient safety. Unfortunately, studies have shown as few as 15 percent of medical errors are reported (Barach & Small, 2000). 

 

Most of the errors remain hidden, under reported and a growing threat to patients -- similar to an iceberg just below the surface of the water.  Safety experts call these latent threats. These are threats that lie in wait like a tiger in tall grass waiting for the exact moment to pounce on its prey. Yes, latent threats are scary because your doctor and nurse are unable to see the potential danger or impending threat to your safety.  


Under reporting of safety events and errors makes it impossible to spot trends, fix system flaws or anticipate future system problems.  So, why don’t healthcare professionals report safety events and what does it mean for your safety?


The most common reasons for under reporting safety events include (Barach & Small, 2000):

  1. Fear of reprisal – the frontline provider fears that the error will lead to their dismissal, punishment or legal action.
  2. Time – busy nurses, physicians and other frontline staff aren’t provided sufficient time to report near misses or system anomalies due to workload and cumbersome reporting systems.
  3. Insufficient urgency – reporting is not understood, encouraged or prioritized as a critical safety behavior by hospital leaders or frontline staff.
  4. Lack of feedback – once reported, the reporter didn’t receive any feedback nor closure about the reported event.

The result is a punitive, suspicious and uninformed hospital patient safety culture that is unable to learn from their errors or near misses, thus leading to a collision with the ‘iceberg.’  Unfortunately, you or one of your family members could be the next ‘Titanic’ due to these hidden threats.


How can you participate in reporting safety events and near misses during your hospital, clinic or office visit?  Patients and family members have a responsibility to report threats to their safety through the hospital complaint system.  Even the word ‘complaint’ has a negative connotation.  No one wants to be a complainer.  I speak with nurse managers who manage patient complaints and most pay careful attention to your complaint. They try to uncover and investigate the root cause of the event or service gap.


Patient complaint systems are your way of being a participant in the patient safety system by pointing out miscues, miscommunication, errors, service gaps and mistakes.  You are a witness to your care.  You have a responsibility to report without fear of reprisal.  Your report could mean the difference between your safety and a potential harmful event.  If you do not report it, the latent error may happen to someone else because the event went unreported.


Some tips for reporting your complaint include being very specific including your direct observations and experiences.  Try to avoid blaming an individual but include all the facts leading up the event and what happened after you discovered the miscue.  Don’t forget to follow-up with the supervisory staff either at your doctor’s office or at the hospital until you are satisfied with the response from the facility.  


Remember, your complaint could be the near-miss report that prevents harm to another patient!


Source:

Barach, P. and Small, S. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. British Medical Journal, 2000 March 18; 320(7237): 759–763.


Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, click here. Follow Steve on Twitter @S_SPowell


Read more columns by Steve Powell here.


©2013 ShareWIK Media Group, LLC


Mar 16

Jim Davies (not his real name) is a veteran of the wars in Iraq and Afghanistan.  He looks older than his 27 years.  His four tours of duty took a toll on this once idealistic young man from the South.  His marriage to his high school sweetheart had ended in divorce during his second tour to Afghanistan.  His ex-wife Sherry had witnessed frightening changes in her husband each time he returned home from his deployments.  


His laid-back demeanor was gone, replaced with night sweats, nightmares and unexpected outbursts.  Jim was tough as nails and assured Sherry that he could handle what was happening and all he needed was more time at home.  Unfortunately, the operations tempo of his elite unit required more time away, less and less time with Sherry and even more frontline patrols where the fighting was intense.


Even though Jim managed to compartmentalize all he experienced in combat, the end of his marriage was the breaking point for this decorated soldier.  He was later diagnosed with PTSD (post-traumatic stress disorder).  Jim was at the lowest point of his young life; confused, numb and looking for answers. He was medically discharged from the service and began receiving treatment at his local VA hospital. 


Jim was met at the entrance of the hospital by a soft-spoken elderly man who had to be in his early seventies.  As the man reached his hand out to shake Jim’s, he said, “So glad to see you. I’m Jesse, Vietnam 1969, 82nd Airborne, what service are you from?”  Jim immediately new he could trust Jesse and said, “I’m Jim, Delta Force.” “Is this your first visit?” Jesse said as he began his routine process for assessing patient needs.  “Yes, this place is much bigger than I expected. I got lost in the parking garage and am running a little late now.” 


Jesse offered his assistance, “Not to worry, let’s see where your appointment is scheduled and I’ll show you the way.”  Jesse continued to ease Jim’s uneasiness during their walk through the halls as he pointed out landmarks for navigation. “You are really going to like the staff here; they are the most caring people I have ever been around; we’re a team here and that team includes you now.” 


Jim knew teams and he felt like Jesse really cared.  During the short walk, Jim became a little more energized than normal; Jesse’s big smile and demeanor were genuine and welcoming.  Although many months of treatment were ahead of him, Jim felt more ready than ever to start getting better.


A recent article on patient engagement has shown that patients who are more actively involved in their care have better, safer outcomes (James, 2013).  Additionally, patients who were more engaged in their care had lower health care costs by as much as 21 percent than those patients who were less involved in their treatment decisions (James, 2013).  


Jim was engaged by Jesse from the minute he entered the hospital. The engaging behavior of Jesse led Jim to become activated; he now had a role on the team.  Jim would need to build new skills, knowledge, abilities and increase his willingness to be an active member of this new team he was joining if he was going to get his life back or begin a new one he hadn’t imagined yet.

Reference:


James, J. (February 14, 2013).  Patient Engagement. People actively involved in their health and health care tend to have better outcomes – and, some evidence suggests, lower costs.  Health Policy Brief, Health Affairs. Accessed at www.healthaffairs.org.


Steve Powell is an experienced facilitator, practitioner, communicator and proven leader with over 25 years of experience in human factors education and teamwork training. For more information, click here. Follow Steve on Twitter @S_SPowell


Read more columns by Steve Powell here.


©2013 ShareWIK Media Group, LLC


©2011 ShareWIK Media Group, LLC. All rights reserved. ShareWIK does not provide medical advice, diagnosis or treatment. For more information, please read our Additional Information, Terms of Use and Privacy Policy.

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