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

April 1, 2004

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

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 fouryears since the infamous Institute of Medicine (IOM) report, To Err is Human:Building a Safer Health System, whipped healthcare consumers, clinicians andrisk managers into a frenzy over the number of preventable medical errors andinfections.

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

Although the frightening statistics were first examined byrenowned 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 werefanned by incendiary media reports, the information was a legitimate wake-upcall to anyone undergoing surgery or being treated in a healthcare facility.

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

In 2001, researchers at the VA Center for Practice Managementannounced that the problem of medical errors was overestimated, with the realtotal between 5,000 and 15,000 deaths attributable to medical errors. The VAstudy examined 111 hospital deaths at seven VA hospitals between 1995 and 1996;the 14 physicians who examined patients medical records reported that 22.7percent of the deaths might have been prevented if they had received optimalcare, while 6 percent of the deaths were probably or definitelypreventable. The researchers found that the physicians had varying opinions onwhether 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 originalstatistics, experts emphasize that its not about the numbers, but a focus onimproving patient safety, period.

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

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

Although the buzzword patient safety has been bandiedabout quite a bit in the last five years, the term needed clarification. TheAgency for Healthcare Research and Quality (AHRQ), the federal organizationtaking a lead in studying and promoting patient safety, crafted this definitionas 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 applicationreduces the probability of adverse events resulting from exposure to thehealthcare 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 JointCommission on the Accreditation of Healthcare Organizations (JCAHO) not onlyissued new National Patient Safety Goals (NPSG), but a Universal Protocol forWrong-site Surgery that is drawing applause from clinicians and patientsafetyadvocates alike.

I am in full agreement with JCAHOs Universal Protocol, McNamara enthuses. I have been instrumental in implementingpolicies and procedures that comply with the protocol in (several healthsystems) and I strongly believe in all of the risk-reduction strategies in theprotocol, such as involving the patient in the marking, corroboration of thecorrect 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 confirmedand documented on a checklist preoperatively. Immediately prior to incision,these criteria should be reviewed with a time-out and all of the surgical teammembers actively involved and centered on the individual patient and theircorrect surgical site. At WakeMed we call this the Pause for the Cause.

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

Also included in JCAHOs NPSGs is a mandate to curbinfections, which occur so frequently that they are listed on hospitalspre-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 proceduresand accomplished 100 percent compliance with criteria 1 and 2. Criteria 3 wasnot met because the literature review demonstrated very minimal research tosupport discontinuing the antibiotic before the patients chest tubes andcentral lines were discontinued and therefore the surgeons disagreed with thiscriteria for this procedure. We have currently added glucose monitoring andtreatment intraoperatively to the antibiotic protocol in the cardiac cluster andwill use the same process for monitoring and quality improvement. The antibioticprotocol and auditing has been started in the orthopedic cluster and this willbe phased in to address all specialties by the end of 2004, to be followed bythe glucose protocols. This is targeted at the reduction of surgical siteinfections. The administrative support to provide staff and financial backing toattend the educational conferences; support from clinical analysis for tool development and datacollection; staff and physician participation; and collaboration with thepreoperative and postoperative nursing units have made all the difference.Enhanced monitoring of surgical site infections with risk analysis beinginitiated where there appears to be a blip has precipitated practice changes insurgical 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, notpeople, thereby allowing them to emphasize changing the system to make itsafer rather than targeting and removing individual bad apples. Werecognize that when individuals repeatedly perform poorly and are unresponsiveto education and remediation, action is necessary. Nevertheless, there isvirtual unanimity among patient-safety experts that a focus on systemic changewill be far more productive than an emphasis on finding and punishing poorperformers.4

Two of the AHRQ studys editorial board members were InternalBleeding authors Wachter and Shojania, who write, Most errors are made bygood but fallible people working in dysfunctional systems, which means thatmaking care safer depends on buttressing the system to prevent or catch theinevitable lapses of mortals. This logical approach is common in other complex, high-techindustries, but it has been woefully ignored in medicine. Instead, we havesteadfastly 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 providersfeeling guilty and demoralized. Most importantly, it hasnt done a damn thing to make healthcare safer.5

Hospitals must provide a blame-free culture in whichemphasis is placed on process improvement, not finger-pointing at theindividuals, McNamara says. Involving all of the practitioners,surgeons, RNs, surgical technologists, and unlicensed personnel inrisk-reduction strategies and quality-improvement processes will enhance acollaborative team approach that fosters integrity in the individual, ablame-free culture with error/near error reduction. Collaboration in building orimproving the process increases compliance and buy-in by the participants andcreates an environment that leads to open communication to clarify correctpatient identification, procedure, site, laterality or level as in spinesurgery. All participants are actively involved and committed toproviding quality safe patient care.

A Culture of Safety

Wachter and Shojania point to British psychologist andprofessor James Reasons Swiss cheese model in which multiple smallerrors in a complex system reach patients only when many holes in the protectivebarriers align to let them through.6 In other words, Wachter and Shojaniaexplain that counting on an individuals competence and good intentions is notenough; the hospital must fix its potentially flawed processes foractions such as checking patient IDs or determining correct surgical sites. Theysay that identifying and analyzing near-misses and errors is critical, since catastrophicfailures almost always reflect deep, widespread problems with the morale andcohesiveness of the workers, how information is shared across departments,whether employees feel safe enough to question the actions of their bosses, andthe safety culture of the organization.7

Researchers David Nash, Laura Pizzi and Neil Goldfarb, fromthe Thomas Jefferson University School of Medicine and the Office of HealthPolicy and Clinical Outcomes, agree, stating, Attention to organizationalissues of structure, strategy and culture may be a promising direction formedicine.8 They advocate the creation of a safety culture in healthcarefacilities: While an exact definition of a safety culture does not exist, arecurring theme in the literature is that organizations with effective safetycultures share a constant commitment to safety as a top-level priority whichpermeates the entire organization.8

Based on numerous studies in the literature, elements of aculture 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 longbefore the IOM study, McNamara emphasizes. Every staff member is investedin safe patient care and patient satisfaction. We adopted JCAHOs NPSGs andimplemented them to enhance our culture of safety. Previous to our October 2003JCAHO survey we aggressively incorporated policies and practices that supportthe NPSGs across our system. We continue to monitor compliance; it is part ofour everyday patient care. A large percentage of our staff is active in theirprofessional associations like AORN, AST and ASPAN. These practitionersconstantly share information on advances in practice to keep us on the cuttingedge of safe patient care. The directors of surgical services at WakeMed meetmonthly with the other directors in our county to standardize policies andprocedures so that the surgeons who use the various facilities will not have tocomply with a variety of different practices related to safe patient care, suchas identification and marking of the surgical site.

The Fine Art of Error Reporting

Historically, medical errors are revealed through morbidityand mortality committee reviews as well as medical malpractice claims data thatyield very few, if any, error-reduction strategies. In addition, errors that donot cause injuries may go undetected.9 Today, healthcare is increasingly takingits cue from the aviation industrys system of near-miss and accidentreporting, but this tactic can only succeed if the aforementioned culture ofsafety is strong and cultivates blame-free error reporting. Culture changesmay have their greatest impact on underground (unreported) errors, whichare 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 patientbecause the error was caught, it is a near miss; if the absence of injury isowed to chance it is a no-harm event.9 Broadening the targets of incidentreporting 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 lesslikely to provoke guilt or other psychological barriers to reporting, and theyinvolve little medico-legal risk. In addition, hindsight bias is less likely toaffect 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 isthe key to providing a pro-active approach to safe patient care, McNamarasays. I dont think healthcare facilities have bought into theprocess within or outside of their facilities. Many organizations have created hotlines to report medicationerrors but other error/nearerror reporting is not far-reaching. I think we needconfidential, anonymous, non-punitive external reporting venues such as AORNsPatient Safety First hotline to report near misses and actual errors. The goalis to gather the contributions into a database that can be analyzed and used toform the basis for the creation of new systems, protocols and procedures thatcan improve patient safety. The key to all initiatives has to be the belief thatthe errors are due to flawed systems and not to individuals.

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

Healthcare incident reporting is taking many forms, such asthe Food and Drug Administration (FDA)s mandatory reporting of major bloodtransfusion reactions, and national surveillance programs such as the NationalNosocomial Infections Surveillance System (NISS) of the Centers for DiseaseControl and Prevention (CDC). In 1995, hospital-based surveillance was mandatedby JCAHO due to the belief incidents resulting in harm (sentinel events, definedas an unexpected occurrence involving death or serious physical orpsychological injury, or the risk thereof) were occurring frequently. JCAHOcreated a Sentinel Event Database that accepts voluntary reports of sentinelevents from member institutions and patients.

Improvement in healthcare incident reporting is necessary,experts say, citing clear evidence of rampant underreporting. While the aviationindustry has processed as many as 30,000 incident reports annually, JCAHOsdatabase collected just 1,152 events in six years.9 The AHRQ report states: Mosthospitals incident reporting systems fail to capture the majority of errorsand near misses. Studies of medical services suggest that only 1.5 percent ofall adverse events result in an incident report and only 6 percent of adversedrug events are identified through traditional incident reporting or a telephonehotline. The American College of Surgeons estimates that incident reportsgenerally capture only 5 to 30 percent of adverse events. A study of a generalsurgery service showed that only 20 percent of complications on a surgicalservice 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 gotcomfortable 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 aboutyour 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 erroranalysis, is the most widely accepted method hospitals use to evaluate medicalerrors. RCAs are is steeped in the methodology of James Reason, whodescribed two major categories of error: active error, which generally occurs atthe point of human interface with a complex system, and latent error, whichrepresents failures of system design. RCAs are used to uncover latent errorsunderlying 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 iscomplete without involvement of risk management principles and personnel.

I think risk managers need a marketing campaign to get outtheir message as to how important they are to preventing medical errors, McNamara says. They hold a plethora of information ontrends of errors and potential errors in the facilities. This information andrisk management principles need to be shared with practitioners at the clinicalinterface. For example, many times the staff does not know they have had aretained sponge error because the patient went to a different surgeon or hospitaland only risk management has been notified. I know for legal reasons that theparticulars should not be shared, but notification of the main issue opens anopportunity to review and revise correct sponge, sharps and instrument countpolicies and procedures and reeducate staff and surgeons, and monitor the compliance. At WakeMed the riskmanagement practitioners sit on the patient safety and environmental safetycommittees and give feedback to the departments on trends in incident reportingto initiate proactive process review.

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

While in an OR huddle, I heard a doctor say, We dontwant to get sued, and reporting is a big hassle, Bower recalls. Ithought, 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, whenit needs to be flipped around to a culture of, Were trying to protect thepatient; the side benefit of which is were not going to get sued. Its afacility attitude, a culture of safety that puts the patient first and the othergood stuff will follow.

A National Witch Hunt?

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

Authors Wachter and Shojania point out that while cliniciansloved 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 2002survey, 1,200 Americans and 800 physicians were asked about the most effectiveways to prevent medical errors; 50 percent of the respondents wanted to suspendthe licenses of healthcare providers who made the mistakes, 40 percent favoredfines, and a small percentage didnt mind additional legal battles. In anothersurvey, just 14 percent of physicians thought releasing information aboutmedical 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 faceof 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 onepersons fault there is usually a faulty system or process involved. Wemust do a better job of making sure clinicians have the skills, tools andsystems they need, and we must keep an eye out for them in a kind, supportiveway, not a punitive way. We must treat people kindly, instead of watching outfor their badness all the time. We must say, Its a complex place and weexpect a lot out of you, but is there anything we can do to make you a betterclinician? We recognize that its a complex issue, and that we need toaddress how to deal with pressure, with escalations of anger and frustration,and the biggest challenge of all effective communication. Every bad thingthat happens usually results from some kind of communication error.

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

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

What Scares Nurses Most

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

I believe the biggest patient safety issue forperioperative nurses is the pressure to multi-task and turn rooms aroundquickly, McNamara says. This creates a sense of urgency for the staff that cancause them to take shortcuts in practice processes. These processes were put inplace to provide a safe environment for the patient and staff. This opens thedoor for errors. The pressure from surgeons and administrators for efficienciesin turnaround times adds increased stress to the staff at the clinicalinterface.

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

Im sure that transplants are a general worry for mostfacilities if you dont have a tight system for verifying blood matches likeyou do with blood transfusions, Bower says. With blood transfusions, theresa very rigorous protocol that has been drilled into you, but it may not be thesame with transplants. After the Duke incident, were getting in the habit ofchecking blood type but we dont have as rigorous a process for it. Weredoing more transplants these days, so it can be a concern.

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

Bower wonders if sometimes hard-to-understand or improperlyprioritized protocols work against them. She explains that for something asserious as compliance with patient-safety mandates, policies and procedures mustbe clear and have personnels collective buy-in in order for them to beeffective.

When its really simple and a mandate everyoneunderstands, then it happens, Bower says. When its ambiguous, it takeslonger to sink in. In ramping up for patient safety goals, everyone jumps on thebandwagon and you get a frenzy of opinions on how to do things. We need thingsto be simple, yet people start making forms with too much stuff on them. Itstops people in their tracks. We need to be better at getting clear in our headsand how to articulate things that really matter and focus on that. Get rid of the fluff and extraneous verbiage. I would like tosee all policies and procedures be patient focused, with clearly delineatedresponsibilities 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 aflatter organization that can focus on teamwork. Its time to bring downthe barriers and include the people doing the work in the decision-making. Theyare overwhelmed with all the shoulds. In a perfect world, leadershipshould make it easier for the frontline workers to do their jobs. We need towork on that culture, and were making small steps forward.

The Perioperative Nurses Role

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

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

The staffing ratios enacted in California will havefar-reaching effects on patients and nurses across this country, McNamarasays. Many states will follow Californias lead. Currently with the nursingshortage 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 thepatient, potentially putting patients at risk. The cost of meeting the staffingratios is sure to become a financial burden to the hospitals who when beingfinancially stressed find cutting staff, the highest expenditure in the budget,the quickest way to gain dollars. There are definitely risks to patient safetywhen working understaffed on a unit. Hospitals need to remember that patientscome there for nursing care, the physician spends minimal time in comparisonwith the hospitalized patient. The hospitals need to invest in nursing, provideenough staff and a safe environment for the staff to provide safe patient care.

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

Pilot Program Teaches Clinical, Business Skills to Increase Patient Safety

ByKelly 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 upto 30 different stakeholders involved in the most basic procedures, yet everyonehas 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 PennsylvaniaMedical Center.

Responding to this need for better comprehensivepatient-safety training, the Hospital of the University of Pennsylvania, theWharton School, and the Leonard Davis Institute of Health Economics of theUniversity of Pennsylvania united last year to create the Penn Medicine PatientSafety Leadership Academy (PSLA). The program takes 42 midlevel clinicalpersonnel physicians, nurses, physician assistants and residents througha seven-month course of intense conferences and case studies that applymanagement practices to strategies to improve patient safety. The pilot programbegan in October 2003 and will run through May 2004.

After nurturing the concept for several years, we havechosen to heavily invest in the development of leadership and management skillsof 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 andthat often we promote our best clinicians to leadership positions but fail togive them any leadership education, says Angela Wurster, RN, MSN, CRNP,executive director of the PSLA. So, the obvious conclusion was if we want ourfaculty, nurses, physician assistants and residents to participate in leadingpatient safety initiatives we need to empower them to do it. Prior to theirparticipation, students were asked to identify particular situations in surgerywhere communication was an issue, as well as their initial ideas of how toimprove dialogue among caregivers. The PSLA emphasizes solutions for real-worldsurgical situations, and much of the academy experience involves work on aspecific patient-safety project through which participants can apply their newleadership skills.

A key element of this program is the team projects, Wurster confirms. It has been an invaluable experience forthe participants. In addition to learning more about patient safety andleadership, 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 teamleader is not the attending physician but rather a resident. There are six teamsfocused on communication among caregivers at various points of care: outpatientpractice to the OR, OR to ICU or PACU, hand-offs occurring because of the newACGME 80-hour workweek regulations, hand-offs that occur during long operativecases, and the discharge process.

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

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

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

The belief is that those closest to the action have theanswers, Wurster says. They get it, they live it, they need to beempowered to assume leadership roles to fix it. Leadership can come from allangles those at the top and those at the so-called bottom. Patient safety isbeing linked to open, intentional, non-blaming communication regardless ofhierarchy or status. When it comes to patient safety, anyone and everyone shouldspeak up. Communication is key.

Despite our best efforts, and despite numerous leaders innursing, many still feel intimidated to speak up and unsure of what they shoulddo when they see errors or things that might lead to errors, she adds. Istill hear people say, No one would listen to me; I am just a resident orjust 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 wewant to learn from all potential and real errors, we have to change the cultureto one from blame and shame.

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

Culture change is difficult...its a marathon, Wurstersays. It happens one person at a time; affect one and hopefully they affectanother. PSLA is attempting to heighten awareness and instill the leadershipskills 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 businessof patient safety, teaching the business/ leadership skills needed to make adifference in patient safety.

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