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The hospital sent Robert Caplan, MD, and Cathie Furman, RN, MHA, vice president of quality and compliance, to the congress, where they led a workshop, “Stopping the Line for Safety: How to Get Zero Defects in Health Care Quality,” which described a proactive effort by the medical center to reduce patient errors. Anyone identifying a patient safety concern that might cause significant harm notifies a patient safety team that is on-call around the clock. The team, including the executive accountable for the reported area, would immediately evaluate the “patient safety alert” and try to prevent the error.

“It’s unique that we make a patient safety alert a top priority, but that is critical to the success of this particular program,” said Charleen Tachibana, RN, MN, chief nursing officer at Virginia Mason. “It’s also a strong message to staff that this work is important.”

“It’s critical that the team have the authority and the accountability to ‘stop the line’ — that is, remove whatever is potentially harmful to the patient whether it’s a product, procedure, or another person,” Furman said. In one instance, an elevator was removed from service because the nursing staff was concerned that it kept breaking down — with unstable patients inside.

Reporting of patient safety alerts is up 35%, but that’s not enough, Furman and Tachibana say. They want to see reports increase to 800 per year so that potentially harmful situations are detected earlier in the process. “We want nurses and other staff to increase their reporting,” Furman said. “We want them to come forward and tell us what is putting them in jeopardy due to process breakdown. We’re starting to fix the things [nurses] deal with every day that have been frustrating to them for years.”

Communication is key

As director of risk management and quality assessment for Beta Healthcare Group in Alamo, Calif., Elaine Bierman, RN, BS, knows the value of good communication. A nurse for 34 years, 14 of them in risk management, she understands how patient safety can be compromised when communication fails. Bierman also attended the congress and was interested in a presentation on the breakdown in communication among the patient, the caregiver, and the hospital. “Patients, Family, Clinician Partnerships that Change Culture: The MITSS Story” was presented by Frederick van Pelt, MD, and Linda Kenney, a patient who was undergoing ankle surgery when van Pelt inadvertently injected nerve block anesthetic into her bloodstream, causing cardiac arrest.

Kenney recovered, but said at first she was denied access to anyone who might help her understand what went wrong. She and van Pelt used their experiences to help patients like Kenney by founding Medically Induced Trauma Support Services (www.mitss.org).

“In addition to providing direct emotional support to patients and families, the mission of MITSS is to serve as an advocate to increase awareness of the emotional impact that these events have on all involved and to promote the development of coordinated follow-up support,” Kenney said. “Patients, families, and clinicians all suffer when adverse events occur and they need to be taken care of.”

Bierman said that Kenney and van Pelt conveyed the importance of disclosure and communication when an adverse event or unanticipated outcome occurs. “We have yet to know if this type of disclosure reduces the incidence of malpractice claims,” she said, it does go a long way toward helping all parties to the event understand what each is going through.”

Bierman thinks that a congress like this highlights practical ways to deal with patient safety. “This kind of conference helps all of us create a safer work environment,” she said. “It’s also motivating to hear speakers who are so committed to providing safe care and good care to patients.”

What was particularly exciting about this congress, Ganser said, was the number of organizations and multidisciplinary teams that came forward to share their own knowledge and best practices. “Learning and sharing have become hallmarks of the patient safety movement,” she said.

Please go to the next page to see the
2004 National Patient Safety Goals