Erasing Med Errors
To create a safer environment for patients, many hospitals employ safety programs to prompt health care professionals to think about, discuss, and—ultimately—eliminate on-the-job mistakes

By H. Cheever Griffin
August 12, 2003

Patricia Smith, RN, patient care coordinator at Beebe Medical Center in Lewes, Del., remembers exactly when it hit her that the errors in the health care profession can mean the difference between life and death.

It was a hectic day decades ago, but Smith, a 34-year veteran, recalls it like it was yesterday. She was dispensing pain medication to a child when she had to step away briefly to address an urgent matter. She quickly returned to dispensing the medicine, but the interruption had caused to her lose sense of how much she had administered.

She caught herself in time to keep from giving her young patient an overdose.

"It really shocked me," Smith said. "Something like that can make a different nurse out of you. It makes you extra cautious and much more thorough in every step you take."

As Smith's recollection illustrates, the issue of patient safety is hardly a new one. What is different about it these days, many nurses and other health care professionals say, is the amount of attention it receives inside and outside the industry.

What helped to start it all was the highly publicized 1999 report "To Err is Human" by the Institute of Medicine. The work, which detailed how tens of thousands of patients die each year because of medical errors, opened the eyes of many Americans to the problem and prompted a collective gasp from the country. Recent headline-grabbing mistakes, from an amputation of the wrong limb to a transplant of an incorrectly matched heart, have fueled the public's consternation.

"Patients have become much more aware of this issue," Smith said. "They're asking more questions, examining more closely the pills they take and getting more involved overall."

All of this is a good thing, Smith and others say. The increased public scrutiny, they contend, has prompted greater action.

From the introduction of patient safety goals by the Joint Commission on Accreditation of Healthcare Organizations to renewed efforts by hospital staffs across the country, the medical community is seen by many to be moving more aggressively to combat mistakes and create a safer environment for patients-and reverse the accidental death figures that so shocked the nation several years ago.

Nearly every discussion with nurses and other health care professionals about patient safety begins with a similar refrain: The No.1 problem is the staffing shortage that has plagued the nursing field for years. The bottom line, health care providers say, is that too few nurses take on too many tasks and patients and work too many hours. All of which is a recipe for medical foul-ups.

"Good people are making mistakes because of the staffing problem," said Mary Foley, past president of the American Nurses Association. "Errors and fatigue are related."

Short of rebuilding the nursing population, however, hospitals around the country are taking various alternative steps to enhance patient safety. So, too, are medical organizations, including JCAHO.

In July 2002, commission officials issued six major patient safety goals and recommendations-the first ever by the organization. Accredited facilities were expected to implement the recommendations, which range from improving the accuracy of patient identification to enhancing the effectiveness of clinical alarm systems, by January.

According to Rick Croteau, MD, executive director for strategic initiatives at JCAHO, the response thus far to the commission's patient safety guidelines has been good, but not great. "We're seeing in general fairly good compliance," Croteau said, "but a number of places are still struggling with some of the recommendations."

One of the recommendations that health care professionals still grapple to implement, Croteau said, is moving away from writing the more common but potentially dangerous abbreviations, acronyms and symbols on medications and orders.

He points to the example of the symbol "u" to represent "units." When written in a rushed manner, Croteau said, the letter can be mistaken for a zero-and thus cause a patient to receive 10 times the appropriate dosage. He adds that too many facilities also do not place zeroes in front of decimal points (e.g., 0.5 instead of .5), which again can lead to delivery of a disastrously high dosage.

"It requires a true behavior change," Croteau said in explaining the difficulty with this particular compliance. "People have gotten into the habit of using certain abbreviations in their professional career and to change now is difficult."

As tough as some of the recommendations may be to implement, health care facilities must comply with them or face an eventual loss of accreditation, Croteau said. He added that JCAHO continues to communicate its safety objectives to its member organizations and provide them with whatever guidance they need to meet them.

Behavior change, nurses and other health care professionals say, is at the heart of not only many of JCAHO's recommendations, but the overall effort to enhance patient safety, and such change starts with moving toward a process that seeks solutions rather than punishment.

"The key is to move away from a culture of blame to one that focuses on fixing the system," Smith said, adding that if workers aren't comfortable talking publicly about their near misses, the larger problems behind them won't be addressed.

She points to her own experience as an example. Her near miss many years ago, she said, made her much more careful and aware-but no official avenue was available to discuss the incident or determine whether it was part of a bigger problem.

Today, nurses and other employees at her Delaware hospital report potential mistakes and openly discuss them in order to look for larger trends or difficulties within the system. "It's important to know about near misses, so we can look at how they happened and come up with ways of correcting them. You can't fix what you don't know."

The Safety Tracking Tool, as officials at Beebe Medical Center call their reporting system, entails filling out a report card about a mistake or near miss and sending it to the appropriate department for review. For example, Smith said, a nurse who discovers that the pharmacy has provided the wrong medication for a patient will produce a detailed description of the incident, from the time and date it occurred to the name and even a photograph of the wrong medication.

"It could be that two similar-sounding medications were stacked next to each other in the pharmacy when they probably shouldn't have been," Smith said. "But you need to fully and openly examine the situation in order to find out what may have happened."

In another sign that points to a growing openness about medical errors and greater efforts to address their possible root causes, a number of private companies have developed patient safety training programs designed to prompt health care professionals to think about, discuss and, ultimately, eradicate on-the-job mistakes.

One such program is SafeStart, a five-week session that focuses on what its developers consider to be the main factors behind most medical mistakes-rushing, frustration, fatigue and complacency. The program, its developers say, helps nurses to work around possible staffing shortages by showing them how to feel less rushed or complacent-thus making them more thorough and cautious in their work.

"We address the human side of mistakes," said Michelle Teeters, product manager for the Texas-based program. "It's largely a commonsense approach that tries to make nurses and others more aware of problematic situations and empower them to change it."

Such empowerment, however, doesn't come cheap. The SafeStart program costs $10,000, and many hospitals have decided on a more inhouse approach. A handful of hospitals have used SafeStart, however, including Athens-Limestone Hospital in Athens, Ala.

"It worked well for us," said Patricia Moss, RN, risk manager for the hospital. "It makes you more aware of why you feel rushed or frustrated and thus helps you gain more control over it."

Non-human factors also influence medical errors. Health care workers around the country say that, undoubtedly, hospital technology-from devices that signal when they are malfunctioning to computer-generated prescriptions that eliminate handwriting-related confusion-has helped enhance patient safety.

At the same time, however, most acknowledge that the seemingly constant influx of new and increasingly complex medical technologies can do more harm than good if not used correctly. "Oftentimes, it's actually the nurses who are running the equipment, so they have to stay on top of this new technology," said Patricia Seifert, MSN, RN, peri-operative cardiac care coordinator at Inova Fairfax Hospital in Falls Church, Va.

Seifert, a former president of the Association of periOperative Registered Nurses, said that one way nurses are staying ahead of the technology curve is by enlisting the help of the equipment makers themselves. "Because the technology has gotten so sophisticated, the trend has been for hospitals and nursing staffs to get the [equipment] companies more involved in training," she said.

Johnson & Johnson, which among other things develops medical equipment, has begun doing just that, spokeswoman Liz Fricke said. The company has started to more actively train nurses on the use of its products. Although it conducts most of its training on an informal basis at the hospitals, Johnson & Johnson recently started a program known as RN Champs, which brings nurses to the company's headquarters-at its own expense-for a two-day equipment training session.

"Nurses are key players, especially in the operating room," Fricke said. "We want to help them to become experts on our technology products so they, in turn, can be the troubleshooters in case anything happens."

As hospitals work in both the arenas of people and products to create a safer patient environment, most observers say much remains to be done-and that until the staffing shortage ends, patient safety will remain a formidable challenge. Nonetheless, Smith insists that nurses and other health care providers will continue doing all they can to ensure that a person's trip to a hospital or clinic is a safe one.

"You're dealing with life and death," Smith said. "You have to keep working to improve the situation."

Contact H. Cheever Griffin at cgcommunications@ameritech.net