Patient Safety First JUNE 2005, VOL 81, NO 6

P A T I E N T S A F E T Y F I R S T

Hi h reliability theory - m and hig ! ly reliable

he Institute of Medicine report To Err is Human: Building a Safer Health System introduced the concept of high reliability T as an amroach to addressing

and reducing e&s in health care. %s theoretical framework proposes that good organizational design and man- agement can prevent accidents.’

HIGHLY RELIABLE ORGANIZATIONS A highly reliable organization is one

that is ”known to be complex and risky, yet safe and effecti~e.”~(p’~) Critical ele- ments of highly reliable organizations include a commitment to safety, a cul- ture of continuous learning and im- provement, and redundancy in safety measures and per~onnel.~ The primary premise of this theory is that although errors can occur within highly reliable organizations, they rarely do so. Another tenet of the theory is that when near misses or errors occur, highly reliable organizations use knowledge gained from the event to prevent similar errors from occurring in the future.

Highly reliable organizations value team work, communication, and learn- ing together. A number of characteristics have been ascribed to highly reliable organizations, including a preoccupation with failure and safety, deference to expertise, sensitivity to operations, a commitment to resilience, and reluctance to simplify interpretation^.',^ In other words, highly reliable organizations 0 focus on identifying how mistakes

can be made, 0 take a team approach to decision

making, 0 understand how decisions may

affect all other activities, 0 use creative problem-solving strate-

gies, and 0 examine errors to determine their

root cause instead of blaming indi-

oraanizations viduals for a problem.

Highly reliable organizations can man- age the unexpected by successfully addressing variations and errors that occur. Team members contribute to a system rather than to individual tasks, and this teamwork contributes to ”mindful perf~rmance.”~

SURGICAL DEPARTMENTS AS HIGHLY RELIABLE ORGANIZATIONS

Are surgical departments highly reli- able organizations? To answer this Question, one first must assess the level ;f teamwork and com- munication and examine how team members learn together. In many ORs, individuals who should be team members actual- ly are performing parallel work. For example, the circulating nurse address- es issues related to instru- mentation and moving the patient from the hold- ing area or same day sur- gery area while the scrub person establishes the sterile field and prepares the instruments, medica- tions, and irrigating solu- tions. At the same time, the anesthesia care provider checks the anes- thesia equipment, med- ications, and any ancil- lary devices or supplies. Often, the surgeon is fin- i s h g : a mocedure in

Highly reliable organizations

have a commitment to safety, a culture

of continuous learning and improvement,

and redundancy in safety

measures and personnel.

1 1

“ 1

another room or making clinical rounds, appearing just in time to say hello to the patient before induction. Although, all these individuals are preparing for the patient’s surgery, they are not necessarily acting as a team. In fact, the preoperative ”time out” may

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be the first time these staff members discuss the specific patient and planned surgery.

These health care workers have limited opportunities to participate in educational activities together, which pre- sents another barrier to effec- tive teamwork. Nurses partic- ipate in continuing nursing education while their physi- cian peers participate in edu- cation specifically targeted to their specialty. In some organ- izations, there are no educa- tional opportunities for ancil- lary personnel, such as surgi- cal technologists, anesthesia technicians, or other assistive personnel. Few opportunities exist for teams to train togeth- er, prepare for emergencies, or drill for low-frequency, hgh- risk events, such as hemor- rhage, shock, or anaphylactic reactions.

In considering whether a surgical department is a highly reliable organization, one must ask whether there is a preoccu- pation with safety or with patient flow and volumes. When clinicians do not consis- tently place patient safety first, they may cut corners (eg, by not taking the time to reconcile surgical counts), or they may ignore safety violations (eg, fail to follow policies related to blood administration by not having two people independ- ently verify a patient’s identi- ty). Although errors will not occur in every instance, the potential for error exists.

In some ORs, deference to expertise persists. A nurse might view the surgeon as the ”captain of the ship,” or the

nurse may not feel he or she has sufficient experience or expertise to address concerns with the surgeon. Nurses also may avoid addressing con- cerns based on the surgeon’s temperament. Similarly, if a surgeon is aware that the cir- culating nurse or scrub person is having a bad day, he or she may not address certain nega- tive behaviors or practices with that individual.

Few opportunities exiit for teams

to train together, prepare for

emergencies, or drill for

lo w-frequency, high-risk events.

Team members may not realize that they have a shared responsibility to speak up if they have a safety concern. Few surgical teams have learned how to take a team approach to decision making, and this makes developing a high reliability organization challenging.

LEARNING TOGETHER Members of any surgical

department can develop a highly reliable organization by considering each of the

principles of high reliability theory and learning together about errors and patient safe- ty. First, individuals working in a specific OR must aban- don work styles that do not promote teamwork and, thus, begin a process to create a synergy of effort.

Working and learning together establishes pathways to safety and helps develop redundancies that promote patient safety. When the sur- geon or anesthesia care provi- der alerts the circulating nurse to concerns about the patient or the procedure, the circulating nurse can monitor the patient’s condition and alert team members to early or subtle signs of a change or complication.

Highly reliable organiza- tions do not simply exist, they are developed through the efforts of individuals teaming up and being willing to ana- lyze near misses or adverse events to determine what conditions contributed to the situation. Then team mem- bers must work together to develop processes and proce- dures to help reduce similar errors in the future.

How TO START Nurses play critical roles in

developing and maintaining highly reliable organizations. Whether the nurse is circulat- ing or scrubbing or is part of the management team, his or her perspective is helpful in identifying and addressing safety concerns. For example, a nurse may notice issues with labeling laboratory specimens,

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verifying patient identity for surgcal procedures or blood administration, or compliance with traffic or mfection control procedures. In these instances, the nurse can work with team members to correct these problems and develop strate- gies to support best practice. Working with team members establishes the foundation for a highly reliable organization.

Every OR has the poten- tial to become a highly reli- able organization. Learning more about the characteris- tics of highly reliable organi- zations and making a com- mitment to make the OR a safer environment is an important first step. 03

SUZANNE C. BEYEA R N , PHD, FAAN

DIRECTOR OF NURSING RESEARCH DARTMOUTH-HITCHCOCK MEOICAL CENTER

LEBANON, N H

NOTES 1. Institute of Medicine, To Err is Human: Building a Safer Health SI stem (Washington, DC: Nation- al/Academy Press, 1999). 2. M S Leonard, A Frankel, "Focusing on high reliability," in Achieving Safe and Reliable Health Care: Strategies and Solutions, ed M S Leonard et a1 (Chicago: Health Administra- tion Press, 2004). 3. K E Weick, "The reduction of medical errors through mindful interdependence," in Medical Error: What Do We Knozo? Whnt Do We Do? ed M M Rosenthal, K M Sutcliffe (San Francisco: Jossey-Bass, 2002) 177-199.

RESOURCES Gaba, D M, et al. "Differences

in safety climate between hospi- tal personnel and naval avia- tors," Human Factors 45 (Summer

Hobgood, C; Hevia, A; Hinchey, P. "Profiles in patient safety: When an error occurs," Academic Emergency Medicine 11

2003) 173-185.

(July 2004) 766-770. Hugh, T B. "New strategies to

prevent laparoscopic bile duct injury-Surgeons can learn from pilots," Surge y 132 (November

Knox, G E; Simpson, K R; Garite, T J. "High reliability peri- natal units: An approach to the prevention of patient injury and medical malpractice claims," [ournal of Healthenre Risk Manage- ment 19 (Spring 1999) 24-32.

Milne, J K. "Managing risk, clinical error, and quality of care," Journal of Obstetrics and Gynaecology Canada: JOGC 24 (September 2002) 717-720.

Ruchlin, H S; Dubbs, N L; Callahan, M A. "The role of lead- ership in instilling a culture of safety: Lessons from the litera- ture," Journal of Healthcare Man- agement 49 Uanuary/February

Sutcliffe, K M. "A mindful infrastructure for increasing reli- ability," Ambulatory Outreach (Spring 2000) 30-34.

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Specialty Hospitals Put Community Health Care at Risk he opening of physician-owned, limited-service Tc ie, specialty) hospitals has led to increased

costs i n health care services, forced cutbacks i n services at other hospitals, and placed access to emergency and trauma services a t risk, according to a Feb 16, 2005, news release from the American Hospital Association (AHA). Specialty hospitals typically focus on financially rewarding services, such as orthopedics or cardiac care, and depend on physician-owners to refer their own patients.

Previous government reports have found that specialty hospitals remove lucrative services from full- service hospitals, treat healthier patients, treat fewer patients with low incomes, and rarely have emergency departments that are open 24 hours a day, seven days a week. These strategies can lead to operating mar- gins as high as 44%, versus the average operating margin of 3.3% for a community hospital.

A recent study sponsored by the A H A and sev- eral state hospital associations reinforces these findings. The study found t h a t when physician- owners shift selected patients and services to limited-service hospitals, access to a variety of critical health services is put at risk for the broad- er community. Lost revenues force cutbacks i n essential programs, such as behavioral health care, outpatient clinics for patients wi th low incomes, and health education, and prevent investment i n new programs and technology. The study's findings have led the AHA to call for Congress to perma- nently ban physician self-referral to limited- service hospitals.

Health Services for Broader Community Put at Risk by "Specialty" Hospitals: Report (news releuse, Wushington, DC: American Hospital Association, Feb 16, 2005).

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