Infection Control Today - 04/2004: ENDING THE BLAME GAME

ENDING THE BLAME GAME
Patient-Safety Experts Advocate a New Approach to Eliminating Medical Errors

By Kelly M. Pyrek

It has been a little more than four years since the infamous Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System, whipped healthcare consumers, clinicians and risk managers into a frenzy over the number of preventable medical errors and infections.

For a while, medical errors became a cottage industry, with TV specials, feature stories in slickcover magazines, even a spate of congressional hearings. Medical mistakes now joined airline and food safety (and, two years later, terrorism) as omnipresent sources of angst in the American zeitgast, observe Robert M. Wachter, MD, and Kaveh G. Shojania, MD, professors of medicine at the University of California San Francisco, in their new book, Internal Bleeding: The Truth Behind Americas Terrifying Epidemic of Medical Mistakes, published in February.

Although the frightening statistics were first examined by renowned patient-safety advocate and Harvard surgeon Lucian Leape, MD in 1994, the repackaged data was a shock to the system. And even though the flames were fanned by incendiary media reports, the information was a legitimate wake-up call to anyone undergoing surgery or being treated in a healthcare facility.

The often-cited 1999 IOM report included statistics from two studies (Colorado/Utah and New York) whose data, when extrapolated to the 33.6 million-plus admissions to U.S. hospitals in 1997, revealed that at least 44,000 and as many as 98,000 Americans die as a result of medical errors annually. At the time, deaths due to medical errors were considered to be the eighth leading cause of death, and the price tag associated with total national costs of preventable adverse events ranged from $17 billion to $29 billion.1

In 2001, researchers at the VA Center for Practice Management announced that the problem of medical errors was overestimated, with the real total between 5,000 and 15,000 deaths attributable to medical errors. The VA study examined 111 hospital deaths at seven VA hospitals between 1995 and 1996; the 14 physicians who examined patients medical records reported that 22.7 percent of the deaths might have been prevented if they had received optimal care, while 6 percent of the deaths were probably or definitely preventable. The researchers found that the physicians had varying opinions on whether a medical error directly contributed to a death, and that they also disagreed on what constituted an error.2

While authors of the IOM report defend the original statistics, experts emphasize that its not about the numbers, but a focus on improving patient safety, period.

I am in the believer camp in relation to the IOM study on medical errors, says Sharon McNamara, RN, MS, CNOR, a member of the board of the Association of periOperative Registered Nurses (AORN) and director of surgical services at WakeMed in Raleigh, N.C., a not-for-profit health system. It created open discussions at the national, local, organization and unit level regarding medical errors. There were few practitioners I spoke with who did not have an error/near-error story from their own experience. This study was a wake-up call to healthcare providers and to patients. This was another turning point in educating patients on how important it is that they become educated and collaborate in their own healthcare.

There are a lot of errors out there, but we must consider how many of them are caught or are reversible, and do they matter vs. those that do cause harm, says Janet Bower, RN, BSN, MHA, a staff nurse and programs operations coordinator at the University of Washington Medical Center in Seattle. I think errors that cause harm are not that high, but yes, there are errors. We must remember that we are in very complex, high-tech settings, and we are asked to do more with less in far more complicated surgeries. As an industry, we are whittling away at medical errors and keeping an eye out for the truly bad things that can cause a lot of harm.

Although the buzzword patient safety has been bandied about quite a bit in the last five years, the term needed clarification. The Agency for Healthcare Research and Quality (AHRQ), the federal organization taking a lead in studying and promoting patient safety, crafted this definition as part of its definitive report, Making Healthcare Safer:

A Critical Analysis of Patient Safety Practices: A patient safety practice is a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the healthcare system across a range of diseases and procedures.3

Wrong-site Surgery and Surgical Site Infections

In an attempt to stamp out medical errors, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) not only issued new National Patient Safety Goals (NPSG), but a Universal Protocol for Wrong-site Surgery that is drawing applause from clinicians and patientsafety advocates alike.

I am in full agreement with JCAHOs Universal Protocol, McNamara enthuses. I have been instrumental in implementing policies and procedures that comply with the protocol in (several health systems) and I strongly believe in all of the risk-reduction strategies in the protocol, such as involving the patient in the marking, corroboration of the correct patient and of all information (medical record, imaging studies, informed consent, etc.), as well as corroboration of the procedure, site, laterality or level, and direct observation of the marked site that is confirmed and documented on a checklist preoperatively. Immediately prior to incision, these criteria should be reviewed with a time-out and all of the surgical team members actively involved and centered on the individual patient and their correct surgical site. At WakeMed we call this the Pause for the Cause.

I dont think patients are bothered when we ask them the same questions five times in our efforts to verify and double-check, Bower says. They know we are doing it for their safety, not because we dont have our act together. Its intimidating for patients we need to be making it easy for them to question, ask and verify. Sometimes patients dont want to get involved; they just want to be taken care of. They must realize its in their best interest to get involved its a partnership.

Also included in JCAHOs NPSGs is a mandate to curb infections, which occur so frequently that they are listed on hospitals pre-op consent forms.

I fully support this action, McNamara says. WakeMed became part of the North Carolina Surgical Infection Prevention Collaborative in which hospitals from across the state chose particular surgical procedures in which they would monitor whether the patients were getting 1) the correct antibiotic 2) within one hour of incision 3) the antibiotic was discontinued within 24 hours. Education of surgeons, nursing staff and anesthesia providers was completed, auditing tools developed and implemented and data sent monthly to the collaborative so that state information could be compiled and shared without identification of particular hospitals.

At WakeMed we chose coronary artery bypass graft procedures and accomplished 100 percent compliance with criteria 1 and 2. Criteria 3 was not met because the literature review demonstrated very minimal research to support discontinuing the antibiotic before the patients chest tubes and central lines were discontinued and therefore the surgeons disagreed with this criteria for this procedure. We have currently added glucose monitoring and treatment intraoperatively to the antibiotic protocol in the cardiac cluster and will use the same process for monitoring and quality improvement. The antibiotic protocol and auditing has been started in the orthopedic cluster and this will be phased in to address all specialties by the end of 2004, to be followed by the glucose protocols. This is targeted at the reduction of surgical site infections. The administrative support to provide staff and financial backing to attend the educational conferences; support from clinical analysis for tool development and data collection; staff and physician participation; and collaboration with the preoperative and postoperative nursing units have made all the difference. Enhanced monitoring of surgical site infections with risk analysis being initiated where there appears to be a blip has precipitated practice changes in surgical prep, catheter care, and preoperative showers, to name a few areas.

No Bad Providers, Only Bad Processes

The authors of the AHRQ study focused on processes, not people, thereby allowing them to emphasize changing the system to make it safer rather than targeting and removing individual bad apples. We recognize that when individuals repeatedly perform poorly and are unresponsive to education and remediation, action is necessary. Nevertheless, there is virtual unanimity among patient-safety experts that a focus on systemic change will be far more productive than an emphasis on finding and punishing poor performers.4

Two of the AHRQ studys editorial board members were Internal Bleeding authors Wachter and Shojania, who write, Most errors are made by good but fallible people working in dysfunctional systems, which means that making care safer depends on buttressing the system to prevent or catch the inevitable lapses of mortals. This logical approach is common in other complex, high-tech industries, but it has been woefully ignored in medicine. Instead, we have steadfastly clung to the view that an error is a moral failure by an individual, a posture that has left patients feeling angry and ready to blame, and providers feeling guilty and demoralized. Most importantly, it hasnt done a damn thing to make healthcare safer.5

Hospitals must provide a blame-free culture in which emphasis is placed on process improvement, not finger-pointing at the individuals, McNamara says. Involving all of the practitioners, surgeons, RNs, surgical technologists, and unlicensed personnel in risk-reduction strategies and quality-improvement processes will enhance a collaborative team approach that fosters integrity in the individual, a blame-free culture with error/near error reduction. Collaboration in building or improving the process increases compliance and buy-in by the participants and creates an environment that leads to open communication to clarify correct patient identification, procedure, site, laterality or level as in spine surgery. All participants are actively involved and committed to providing quality safe patient care.

A Culture of Safety

Wachter and Shojania point to British psychologist and professor James Reasons Swiss cheese model in which multiple small errors in a complex system reach patients only when many holes in the protective barriers align to let them through.6 In other words, Wachter and Shojania explain that counting on an individuals competence and good intentions is not enough; the hospital must fix its potentially flawed processes for actions such as checking patient IDs or determining correct surgical sites. They say that identifying and analyzing near-misses and errors is critical, since catastrophic failures almost always reflect deep, widespread problems with the morale and cohesiveness of the workers, how information is shared across departments, whether employees feel safe enough to question the actions of their bosses, and the safety culture of the organization.7

Researchers David Nash, Laura Pizzi and Neil Goldfarb, from the Thomas Jefferson University School of Medicine and the Office of Health Policy and Clinical Outcomes, agree, stating, Attention to organizational issues of structure, strategy and culture may be a promising direction for medicine.8 They advocate the creation of a safety culture in healthcare facilities: While an exact definition of a safety culture does not exist, a recurring theme in the literature is that organizations with effective safety cultures share a constant commitment to safety as a top-level priority which permeates the entire organization.8

Based on numerous studies in the literature, elements of a culture of safety include:

  • Acknowledgment of the high-risk, error-prone nature of an organizations activities
  • Creation of a blame-free environment where individuals are able to report errors or close calls without punishment
  • Expectation of collaboration across ranks to seek solutions to vulnerabilities, and
  • Willingness on the part of the organization to direct resources to address safety concerns

Recommendations made in the IOM report for establishing a safety culture include:

  • Establishing a national focus to create leadership, research, tools and protocols to enhance the knowledge base about safety
  • Identifying and learning from errors through immediate and strong mandatory reporting efforts, as well as the encouragement of voluntary efforts
  • Raising standards and expectations for improvements in safety through oversight organizations and professional groups
  • Creating safety systems inside healthcare organizations through the implementation of safe practices at the delivery level

WakeMed has developed and nurtured a culture of safety long before the IOM study, McNamara emphasizes. Every staff member is invested in safe patient care and patient satisfaction. We adopted JCAHOs NPSGs and implemented them to enhance our culture of safety. Previous to our October 2003 JCAHO survey we aggressively incorporated policies and practices that support the NPSGs across our system. We continue to monitor compliance; it is part of our everyday patient care. A large percentage of our staff is active in their professional associations like AORN, AST and ASPAN. These practitioners constantly share information on advances in practice to keep us on the cutting edge of safe patient care. The directors of surgical services at WakeMed meet monthly with the other directors in our county to standardize policies and procedures so that the surgeons who use the various facilities will not have to comply with a variety of different practices related to safe patient care, such as identification and marking of the surgical site.

The Fine Art of Error Reporting

Historically, medical errors are revealed through morbidity and mortality committee reviews as well as medical malpractice claims data that yield very few, if any, error-reduction strategies. In addition, errors that do not cause injuries may go undetected.9 Today, healthcare is increasingly taking its cue from the aviation industrys system of near-miss and accident reporting, but this tactic can only succeed if the aforementioned culture of safety is strong and cultivates blame-free error reporting. Culture changes may have their greatest impact on underground (unreported) errors, which are extremely difficult to quantify, says the AHRQ report.8

Incident reports encompass three categories: adverse events, no-harm events, and near misses. Researchers Heidi Wald, MD, and Kaveh Shojania, MD explain that when an error does not result in an adverse event for a patient because the error was caught, it is a near miss; if the absence of injury is owed to chance it is a no-harm event.9 Broadening the targets of incident reporting to include no-harm events and near misses offers several advantages; these events occur 3 to 300 times more often than adverse events, they are less likely to provoke guilt or other psychological barriers to reporting, and they involve little medico-legal risk. In addition, hindsight bias is less likely to affect investigations of no harm events and near misses, they write.

Near-miss reporting has tremendous value, Bower says. But some people like to report while others dont want their names on any forms so they never report near-misses. It would be lovely if all of our reporting was near-misses and we never had a real error; theyre out there, and we need to talk about all the scary things weve avoided.

I think that the negative outcome/near miss reporting is the key to providing a pro-active approach to safe patient care, McNamara says. I dont think healthcare facilities have bought into the process within or outside of their facilities. Many organizations have created hotlines to report medication errors but other error/nearerror reporting is not far-reaching. I think we need confidential, anonymous, non-punitive external reporting venues such as AORNs Patient Safety First hotline to report near misses and actual errors. The goal is to gather the contributions into a database that can be analyzed and used to form the basis for the creation of new systems, protocols and procedures that can improve patient safety. The key to all initiatives has to be the belief that the errors are due to flawed systems and not to individuals.

McNamara says that AORN works hard to support perioperative nurses by providing education, Standards of Practice, and research. AORNs Patient Safety First is a milestone initiative that provides a Web site (www.patientsafetyfirst.org) to access a wealth of patient safety-related resources, anecdotal reports of near misses and actual errors witnessed in the surgical setting. These can be reported in confidence and with complete anonymity at patientsafetyfirst@aorn.org. AORN encourages the participation of all perioperative nurses in a forum in which judgment is withheld and the goal of improving patient safety is the ultimate objective.

Healthcare incident reporting is taking many forms, such as the Food and Drug Administration (FDA)s mandatory reporting of major blood transfusion reactions, and national surveillance programs such as the National Nosocomial Infections Surveillance System (NISS) of the Centers for Disease Control and Prevention (CDC). In 1995, hospital-based surveillance was mandated by JCAHO due to the belief incidents resulting in harm (sentinel events, defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof) were occurring frequently. JCAHO created a Sentinel Event Database that accepts voluntary reports of sentinel events from member institutions and patients.

Improvement in healthcare incident reporting is necessary, experts say, citing clear evidence of rampant underreporting. While the aviation industry has processed as many as 30,000 incident reports annually, JCAHOs database collected just 1,152 events in six years.9 The AHRQ report states: Most hospitals incident reporting systems fail to capture the majority of errors and near misses. Studies of medical services suggest that only 1.5 percent of all adverse events result in an incident report and only 6 percent of adverse drug events are identified through traditional incident reporting or a telephone hotline. The American College of Surgeons estimates that incident reports generally capture only 5 to 30 percent of adverse events. A study of a general surgery service showed that only 20 percent of complications on a surgical service ever resulted in discussion at morbidity and mortality rounds.9

We must make it OK to report and talk about medical errors, Bower says. Our facilitys anesthesiologists review cases and errors, and got comfortable talking about them. They set a good example by modeling behavior its a Ill talk about my mistakes so its a lot easier to talk about your mistakes kind of approach. We may not do that as well if at all in nursing, so we face areas of improvement.

Getting to the Root of the Problem

Root cause analysis (RCA), a retrospective approach to error analysis, is the most widely accepted method hospitals use to evaluate medical errors. RCAs are is steeped in the methodology of James Reason, who described two major categories of error: active error, which generally occurs at the point of human interface with a complex system, and latent error, which represents failures of system design. RCAs are used to uncover latent errors underlying adverse events and are characterized by assigning blame to systems, not to individuals.10

Proper incident analysis through an RCA involves:

  • Data collection the establishment of what happened through structured interviews, document review, and/or field observation to generate a sequence or timeline of events preceding and following the event
  • Data analysis a process to examine the sequence of events generated above with the goals of determining the common underlying factors, including establishment of how the event happened (identification of active failures in the sequence) and establishment of why the event happened through identification of latent failures in the sequence which can be generalized.

Cue the Risk Managers

No discussion of patient safety, medical errors and RCAs is complete without involvement of risk management principles and personnel.

I think risk managers need a marketing campaign to get out their message as to how important they are to preventing medical errors, McNamara says. They hold a plethora of information on trends of errors and potential errors in the facilities. This information and risk management principles need to be shared with practitioners at the clinical interface. For example, many times the staff does not know they have had a retained sponge error because the patient went to a different surgeon or hospital and only risk management has been notified. I know for legal reasons that the particulars should not be shared, but notification of the main issue opens an opportunity to review and revise correct sponge, sharps and instrument count policies and procedures and reeducate staff and surgeons, and monitor the compliance. At WakeMed the risk management practitioners sit on the patient safety and environmental safety committees and give feedback to the departments on trends in incident reporting to initiate proactive process review.

Being pro-active, however, requires shining a light on a sometimes dark, engrained operating room culture.

While in an OR huddle, I heard a doctor say, We dont want to get sued, and reporting is a big hassle, Bower recalls. I thought, No, thats not right, but I understand why surgeons feel that way. It always looks like we are trying to protect the hospital from being sued, when it needs to be flipped around to a culture of, Were trying to protect the patient; the side benefit of which is were not going to get sued. Its a facility attitude, a culture of safety that puts the patient first and the other good stuff will follow.

A National Witch Hunt?

The IOM report may have been particularly damning in the eyes of healthcare consumers who were fed up with managed care. The evidence: A 1998 poll of Americans ranked hospitals just above the Internal Revenue Service and just below the U.S. Postal Service; a 1999 Harris poll revealed that less than 40 percent of Americans had confidence in the healthcare system overall.11

Authors Wachter and Shojania point out that while clinicians loved the blame-the-system-not-the-individual approach of the IOM report, healthcare consumers were ready for a witch hunt. They report that in a 2002 survey, 1,200 Americans and 800 physicians were asked about the most effective ways to prevent medical errors; 50 percent of the respondents wanted to suspend the licenses of healthcare providers who made the mistakes, 40 percent favored fines, and a small percentage didnt mind additional legal battles. In another survey, just 14 percent of physicians thought releasing information about medical mistakes was a good idea, while 62 percent of the public thought it was.11

While facilities are not turning the other way in the face of a medical error, they are recognizing that people are human, Bower says. When you dig deeper and ask why an error occurred, its not usually one persons fault there is usually a faulty system or process involved. We must do a better job of making sure clinicians have the skills, tools and systems they need, and we must keep an eye out for them in a kind, supportive way, not a punitive way. We must treat people kindly, instead of watching out for their badness all the time. We must say, Its a complex place and we expect a lot out of you, but is there anything we can do to make you a better clinician? We recognize that its a complex issue, and that we need to address how to deal with pressure, with escalations of anger and frustration, and the biggest challenge of all effective communication. Every bad thing that happens usually results from some kind of communication error.

Wachter and Shojania write, Most organizational errors are made by well-intentioned human beings most highly educated, well trained and experienced - who have become accustomed to small glitches, routine foul-ups, and a culture that suppresses doing much about them.12 Whats more, medical mistakes could be chalked up to slips, inadvertent, unconscious lapses in the performance of an automatic task, as opposed to mistakes, which result from incorrect choices. Thus while most people associate medical errors with untrained, inexperienced or incompetent caregivers, most of our errors are made by ... competent caregivers who perform their tasks so well that they have become almost second nature. Doctors and nurses are most likely to slip doing something they have done correctly a thousand times.13

James Reason adds, Errors are largely unintentional. It is very difficult for management to control what people did not intend to do in the first place.13

What Scares Nurses Most

Its no surprise that hurriedness is a factor in many medical errors and near-misses.

I believe the biggest patient safety issue for perioperative nurses is the pressure to multi-task and turn rooms around quickly, McNamara says. This creates a sense of urgency for the staff that can cause them to take shortcuts in practice processes. These processes were put in place to provide a safe environment for the patient and staff. This opens the door for errors. The pressure from surgeons and administrators for efficiencies in turnaround times adds increased stress to the staff at the clinical interface.

What scares Bower, she says, is handling transplants in the wake of the Duke University blood-type mix-up that resulted in a patients death.

Im sure that transplants are a general worry for most facilities if you dont have a tight system for verifying blood matches like you do with blood transfusions, Bower says. With blood transfusions, theres a very rigorous protocol that has been drilled into you, but it may not be the same with transplants. After the Duke incident, were getting in the habit of checking blood type but we dont have as rigorous a process for it. Were doing more transplants these days, so it can be a concern.

She acknowledges that overall, healthcare workers are far more aware of safety in general, for themselves and for their patients. Ive been in the OR since 1985 and its amazing how far weve come. We used to pick things up with our bare hands or get splashed in the face ... now were much more careful about following protocols.

Bower wonders if sometimes hard-to-understand or improperly prioritized protocols work against them. She explains that for something as serious as compliance with patient-safety mandates, policies and procedures must be clear and have personnels collective buy-in in order for them to be effective.

When its really simple and a mandate everyone understands, then it happens, Bower says. When its ambiguous, it takes longer to sink in. In ramping up for patient safety goals, everyone jumps on the bandwagon and you get a frenzy of opinions on how to do things. We need things to be simple, yet people start making forms with too much stuff on them. It stops people in their tracks. We need to be better at getting clear in our heads and how to articulate things that really matter and focus on that. Get rid of the fluff and extraneous verbiage. I would like to see all policies and procedures be patient focused, with clearly delineated responsibilities shared among the team, to get rid of discrepancies.

Bower says its a matter of changing a facilitys culture; getting rid of the bureaucracy that can work against clinicians, and creating a flatter organization that can focus on teamwork. Its time to bring down the barriers and include the people doing the work in the decision-making. They are overwhelmed with all the shoulds. In a perfect world, leadership should make it easier for the frontline workers to do their jobs. We need to work on that culture, and were making small steps forward.

The Perioperative Nurses Role

The perioperative nurse is the one constant in coordinating the care the patient receives throughout their surgical event, says McNamara. They are the watchdogs who oversee the entire patient experience. The perioperative nurse employs a holistic approach to the patient and their individualized care plan with the patients safety at the core of the plan. This nurse oversees the operative environment to be sure that all risks are controlled and that the team is ready to meet the individual patients needs.

Yet many facilities are bearing the brunt of the nursing shortage, a big piece in the patient-safety puzzle. New staffing ratios are designed to address increasing evidence that a stronger presence of qualified staff can reduce medical mistakes.

The staffing ratios enacted in California will have far-reaching effects on patients and nurses across this country, McNamara says. Many states will follow Californias lead. Currently with the nursing shortage it will be difficult for hospitals to provide these staffing levels; this may create closure of units and a decrease in access to care for the patient, potentially putting patients at risk. The cost of meeting the staffing ratios is sure to become a financial burden to the hospitals who when being financially stressed find cutting staff, the highest expenditure in the budget, the quickest way to gain dollars. There are definitely risks to patient safety when working understaffed on a unit. Hospitals need to remember that patients come there for nursing care, the physician spends minimal time in comparison with the hospitalized patient. The hospitals need to invest in nursing, provide enough staff and a safe environment for the staff to provide safe patient care.

Wachter and Shojania look on the bright side. Like peace officers, firefighters and members of other life-saving professions, most medical caregivers will be there when you need them, will know what they are doing, and will try to do the right thing and will usually succeed.14

Pilot Program Teaches Clinical, Business Skills to Increase Patient Safety

By Kelly M. Pyrek

An increasing number of experts are convinced that patient safety requires a holistic approach, involving and empowering various clinical personnel from all points on the healthcare-delivery spectrum.

Surgery is a highly complicated management process, with up to 30 different stakeholders involved in the most basic procedures, yet everyone has a role to play in patient safety, from start to finish, says Jim Mullen, MD, professor and vice chair of surgery at the University of Pennsylvania Medical Center.

Responding to this need for better comprehensive patient-safety training, the Hospital of the University of Pennsylvania, the Wharton School, and the Leonard Davis Institute of Health Economics of the University of Pennsylvania united last year to create the Penn Medicine Patient Safety Leadership Academy (PSLA). The program takes 42 midlevel clinical personnel physicians, nurses, physician assistants and residents through a seven-month course of intense conferences and case studies that apply management practices to strategies to improve patient safety. The pilot program began in October 2003 and will run through May 2004.

After nurturing the concept for several years, we have chosen to heavily invest in the development of leadership and management skills of these clinical leaders, anticipating downstream benefits on patient safety, Mullen adds.

The academy was initiated out of two basic premises: recognition that those closest to the action usually have the answers and that often we promote our best clinicians to leadership positions but fail to give them any leadership education, says Angela Wurster, RN, MSN, CRNP, executive director of the PSLA. So, the obvious conclusion was if we want our faculty, nurses, physician assistants and residents to participate in leading patient safety initiatives we need to empower them to do it. Prior to their participation, students were asked to identify particular situations in surgery where communication was an issue, as well as their initial ideas of how to improve dialogue among caregivers. The PSLA emphasizes solutions for real-world surgical situations, and much of the academy experience involves work on a specific patient-safety project through which participants can apply their new leadership skills.

A key element of this program is the team projects, Wurster confirms. It has been an invaluable experience for the participants. In addition to learning more about patient safety and leadership, they are learning how to come to together as a team to enact change. We have removed the traditional hierachial system; in some cases, the team leader is not the attending physician but rather a resident. There are six teams focused on communication among caregivers at various points of care: outpatient practice to the OR, OR to ICU or PACU, hand-offs occurring because of the new ACGME 80-hour workweek regulations, hand-offs that occur during long operative cases, and the discharge process.

Wurster explains that all participants completed pre- and postknowledge assessment surveys both on their leadership knowledge and patient-safety know-how. Initial analysis of the pre-program data reveals participants, by self-determination, have a low portfolio of strategies for reducing patient risk and desire enhanced leadership skills to improve patient safety. They indicated they would like to take a leadership role in improving patient safety but need more training to do it.

We have speakers like Jim Bagian and John Nance, both of whom drew eye-opening parallels to the aviation industry. Additionally, our keynote speaker at the end will be Dr. Danny Jacobs, current chair of the department of surgery at Duke University who will speak to the group about the transplant incident that occurred there. Finally, the participants read Atul Gawandes book, Complications.

The PSLA embraces a team approach to problem-solving, showing participants that leadership is blind to rank, experience or job title.

The belief is that those closest to the action have the answers, Wurster says. They get it, they live it, they need to be empowered to assume leadership roles to fix it. Leadership can come from all angles those at the top and those at the so-called bottom. Patient safety is being linked to open, intentional, non-blaming communication regardless of hierarchy or status. When it comes to patient safety, anyone and everyone should speak up. Communication is key.

Despite our best efforts, and despite numerous leaders in nursing, many still feel intimidated to speak up and unsure of what they should do when they see errors or things that might lead to errors, she adds. I still hear people say, No one would listen to me; I am just a resident or just a nurse. I still hear people say, The system is too overwhelming ... how would I possibly change that? If we want to improve patient safety, if we want to learn from all potential and real errors, we have to change the culture to one from blame and shame.

More than anything, the PSLA hopes to teach participants how to create cultures of safety at their hospitals.

Culture change is difficult...its a marathon, Wurster says. It happens one person at a time; affect one and hopefully they affect another. PSLA is attempting to heighten awareness and instill the leadership skills needed to enact change. So much goes into patient safety - decision-making, leadership, negotiations, healthcare finance, communication, project management, stakeholder analysis so the PSLA is about the business of patient safety, teaching the business/ leadership skills needed to make a difference in patient safety.

For more information on the PSLA, go to www.uphs.upenn.edu/surgery/psla

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