It's been more than 13 years since the patient-safety movement spread its roots with the arrival of the landmark report, To Err is Human. But, why is it that, despite the preponderance of evidence, some doctors still aren't washing their hands or running through a quick checklist before surgery?
The Agency for Healthcare Research and Quality recently updated its own landmark report on the topic, 2001's Making Healthcare Safer, looking to review the evidence and share the best practices. A "huge" amount of scientific evidence has hit the industry since then and researchers wanted to address it, Robert Wachter, M.D., patient safety guru, told me by phone last week. Wachter, a professor and chairman of the University of California-San Francisco Department of Medicine, and one of the authors of the report, wrote a textbook on patient safety in 2007, and the second edition released last year was 50 percent thicker, with twice as many references.
Yet still, doctors aren't practicing hand hygiene (some are floating at a 40 to 60 percent compliance rate), or are ignoring other rudimentary safety practices. Wachter says it's to the point where hospitals may need to move past just educating or giving feedback if doctors and nurses won't get on the proverbial bus.
"Once we have decided this is absolutely the right thing to do for our patients, what are the consequences for individual clinicians when they don't do it?" he says. "Our report wasn't designed to address that, but when you look at a practice like hand hygiene or the use of evidence-based checklists to prevent some surgical complications or central line infections, we simply have to get past the phase where we're cajoling people and educating people and building systems. Those are really important, but I think we are at the phase with some of these practices where the time is right to say, ‘You must do this if you're going to work here.' "
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices examines the evidence for 41 different strategies. And it "strongly encourages" hospitals to adopt the top 10 on the list, which are:
- Preoperative checklists and anesthesia checklists to prevent operative and postoperative events
- Bundles that include checklists to prevent central line-associated bloodstream infections
- Interventions to reduce urinary catheter use, including catheter reminders, stop orders or nurse-initiated protocols
- Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia
- Hand hygiene
- The do-not-use list for hazardous abbreviations
- Multicomponent interventions to reduce pressure ulcers
- Barrier precautions to prevent health care-associated infections
- Use of real-time ultrasonography for central line placement
- Interventions to improve prophylaxis for venous thromboembolisms
Wachter says it is surprising that some hospitals still haven't gotten traction on some of these key safety measures. Sometimes, it's just a lack of systems. You want doctors to ritualistically wash their hands? You need gel dispensers every 2 or 3 feet, an educational campaign, feedback, or sometimes even cameras or electronic monitoring systems to observe employees.
Other times, the reasons run deeper and it's about fractured relationships between the institution and its clinicians. At Wachter's hospital, an audit strategy has been used to transform patient safety. Secret shoppers measure compliance. Through the audit program, the hospital also gathers feedback from clinical units, compares different departments, employs a "pride and shame" method to move people along, and education.
"Over time, the needle moves," he says. "You're a really busy doctor or nurse and you're running in and out of patient rooms all day long, it's a little bit of a pain to clean your hands every time you see a patient, and you have to become convinced that this is absolutely the right thing to do, unambiguously."
The movement has shifted over the past dozen years to thinking much more ambitiously about where harm can be avoided. Early on it was just about avoiding medical mistakes such as remembering to take a sponge out of a patient's belly or to operate on the right limb. Now, doctors are recognizing that taking the right steps or using new technologies can help to prevent certain infections or delirium or improperly inserted catheters.
And more broadly, Wachter is encouraged by the industry's evolving emphasis on context — Why did a practice work in someone else's hospital, but not mine? — as well as on culture in adopting a patient safety strategy, something that is highlighted in the new report. All the gizmos and gadgets mean nothing without the having right people run them. Plus, programs must have certain elements baked in for them to sustain over the long term, rather than petering out after a few years.
"You can have a checklist or a computer system, but if people are not communicating to each other well, people are not willing to own up to their errors and talk about them openly, then you won't improve safety very well," Wachter says.
How far along has your hospital come since the dawn of the patient safety movement? Is this a tired topic that you've already mastered, or is it a constant battle to get doctors to follow best practices every single time? Share your thoughts in the comment section.