Chapter 154: Patient Safety

• The science of patient safety has evolved over the past decade, leading to our current understanding of PS as a discipline that utilizes a systems approach to improving healthcare processes and outcomes.

• Medical errors and adverse events are most often the result of systems flaws, not character flaws, as demonstrated by the “Swiss cheese” model of organizational accidents developed by James Reasons.

• A culture of safety is characterized not as “blame-free,” but as a “culture of accountability” in which leaders support and encourage clinicians to make safe choices that can reduce the risk of harm to pediatric patients.

• Medication safety is a particular concern in the pediatric emergency care setting due to the hectic environment in the emergency department (ED), a lack of standard pediatric drug dosing and formulations, and the use of IT systems that frequently lack pediatric safety features.

• Reduction in harm requires the active involvement of leaders who make patient safety a priority, create a strategy and structure for improvement, and foster an environment of teamwork and mutual respect.

• Multidisciplinary, high-performing teams are essential for safe care of children in the ED.

• A growing body of evidence shows that effective teamwork and communication among healthcare providers are linked to better patient outcomes.

“Patient safety” was at one time something that many patients and healthcare providers assumed. After all, no clinician comes to work to hurt anyone, and patients entrust their care to highly trained and dedicated healthcare professionals to provide the best care, and certainly to keep them safe. Yet over the past decade, we have gained a whole new understanding of the concept of “patient safety.” In November 1999, we learned from the IOM report, “To err is human,” that 44,000 to 98,000 people die from medical errors each year in this country.¹ In the ensuing years we learned that the scope of harm was even greater, and the definition of patient safety evolved from efforts to “prevent unintended harm” to a discipline that utilizes a systems approach to improving healthcare processes and outcomes.² The complexity of modern healthcare has surpassed the capability of any single provider and requires a shift from a focus on individual performance to the application of systems thinking, safety science, and teamwork.² In this chapter, we will describe a framework for providing safe and reliable care to children in the emergency department (ED) setting (Fig. 154-1).

Though emergency services personnel and ED providers are hardworking and well intended, they sometimes lack the training, tools and resources required to provide safe, high-quality care to children in the emergency setting.³ This problem was described two decades ago in a 1993 report published by the Institute of Medicine (IOM), entitled, “Emergency Medical Services for Children.”⁴ The report stated that many EMS systems and hospital EDs in the United States. were not capable of providing the same level of care for children as for adults, as evidenced by several studies demonstrating higher morbidity and mortality rates for pediatric versus adult patients treated in EDs for life-threatening events.^5,6

Thirteen years later a second IOM report on the US emergency care system was published, and one segment of this three part report was devoted to pediatric emergency care.⁷ The report, entitled “Emergency Care for Children: Growing Pains,” described the persistence of significant weaknesses in the emergency care system, including lack of sufficient pediatric emergency care training and continuing education for ED staff, and wide variation in treatment patterns for common pediatric emergencies such as stabilization, pain control, and child abuse. The report indicated that only 6% of EDs had all supplies and equipment deemed essential for managing pediatric emergencies, and many lacked pediatric-specific medication dosing strategies and guidelines.⁷

Medication safety remains a particular concern in the pediatric emergency care environment due to a number of factors, including a lack of standard pediatric drug dosing and formulations, a hectic environment with frequent interruptions of care providers, lack of medication safety experts (such as clinical pharmacists) on the ED care team, and use of information technology systems that lack pediatric safety features. In addition, emergency care is often characterized by numerous transitions in care and hand-offs of patients from one healthcare provider to another, sometimes leading to communication breakdowns and adverse events. As we have gained an increased awareness of the risk of harm to children in emergency settings, we have learned there is no simple solution or single approach to keeping pediatric patients safe. Rather, improving patient safety requires strong leadership and role modeling, thorough knowledge of patient safety concepts and improvement science, development of a culture of safety, and a focus on data-driven improvement.⁸

A critical factor in improving patient safety in the ED is overt, visible and continuous commitment and participation of ED leaders who understand that patient safety is a journey and not a one time, or even short-term effort. Reduction in harm requires a multifaceted approach in which leaders work to set priorities, create a strategy and structure for improvement, and foster an environment that encourages and supports safe and reliable care.⁹ Such an environment cannot exist without the collaborative commitment of operational and clinical leaders, including ED physicians and nurses who are willing to serve as role models and lead by example.

The Institute for Healthcare Improvement has described specific steps that leaders can take to achieve safety.¹⁰ Modified for the emergency care setting, these steps include:

1. Establish, oversee, and visibly communicate safety priorities for the ED. Set meaningful goals and celebrate successes.

2. Define and identify harm, design and implement strategies to mitigate risk and prevent harm, and measure/track progress over time. Respond to data and share outcomes.

3. Assess the culture for safety and act to close any gaps. Foster communication and teamwork, provide a model for fairness and accountability, and create an environment of mutual respect.

4. Understand the science of improvement and reliability—strive to be a high-reliability organization (HRO). Ensure the technical and cognitive competence of each individual on the care team, and provide education and tools to successfully drive improvement.

5. Embrace and foster transparency. Share performance data openly with bedside providers, patients and their families. Support transparency and disclosure at the time of adverse events or unanticipated outcomes.

6. Engage physicians and nurses in patient safety improvement efforts, especially those in formal and informal leadership roles.

The delivery of safe, reliable care is no accident. Rather, through an approach based on human factors and reliability science, hospital and ED leaders can design safety into their systems in such a way as to lead to improved risk identification and mitigation and, ultimately, prevention of harm. Adverse events have traditionally been attributed to human failure, and individual healthcare providers have been reprimanded or punished for not meeting expectations to perform at a level of perfection unattainable by any of us. A well-recognized example is the requirement for clinicians to perform mathematical calculations when ordering and drawing up medications for children, especially at the time of an emergency when the stress level is high and distractions are numerous. There are ample examples in the literature of physicians and nurses making math errors,^11,12 including decimal point errors that can lead to tragic results for infants and children. Sadly, the response by administrative leaders has sometimes been to fire the individual who made the math mistake, rather than creating a system that would prevent the same error by the next provider.

The “Swiss cheese model of organizational accidents” developed by James Reason demonstrates that unintended and unanticipated patient outcomes most commonly represent a system or process defect, or a failure of communication or teamwork, rather than an individual failure.¹³ When these systems failures line up, like holes in pieces of Swiss cheese, the impact can reach all the way to the patient, sometimes resulting in harm. Changes in systems or processes can be made to strengthen the defense of the system, that is, “plugging up” some of the holes in the Swiss cheese, so the event is blocked and does not reach the patient. When leaders understand core safety concepts such as this, they can begin to transition from a punitive approach to adverse event analysis to one that focuses on the failures and resilience of systems.¹⁴ The transition to a system-based focus, rather than a focus on individual failures, however, should not be understood as shifting to a “no-blame” culture. Rather, the transition should be to a “Just Culture,” or a culture of accountability, as described by David Marx.¹⁵ Healthcare professionals make choices every day in the workplace setting, such as the choice to wash one's hands before and after examining patients. The Just Culture model provides a framework for managing behavioral choices, supporting and encouraging clinicians to make “safe choices” that can reduce the risk of harm to patients.

The system-based approach to patient safety must be taken by ED leaders as they strive to improve pediatric patient safety, especially in settings with a low volume of ill and injured children. Assessing equipment and medication needs, monitoring knowledge and skill-based competencies of providers, and reviewing and learning from safety events can improve pediatric readiness and, thus, improve patient safety for children in the ED.¹⁶ The ability to recognize and address systems and process failures (i.e., to find and fix defects) is a key component of a comprehensive and effective patient safety program. Applying this same rigor to the evaluation of “near miss” or “close call” events is equally important, so that safety defenses can be strengthened, and patient harm can be avoided.

A successful patient safety program requires knowledgeable senior leaders and middle managers who can provide training and support for front-line providers. Multidisciplinary care teams in the ED need knowledge and tools to develop and implement strategies to reduce risk. The concept of a comprehensive unit-based safety program (CUSP) has been described by Pronovost and others,¹⁷ and activities included in local programs may vary. As an example, leaders in the ED can conduct patient safety rounds as described by Shaw et al.¹⁸ and hold regularly scheduled (monthly) meetings during which patient safety data are reviewed and patient safety concerns discussed. Improvement priorities can then be established and plans to resolve issues developed and executed. The team's activities should be monitored and reported through the performance improvement infrastructure at the unit level, then up to senior leadership, and ultimately to the governing body of the organization. Whatever the structure of the local patient safety program, the primary goal is to decrease harm by designing safe systems, developing and implementing risk-reduction strategies, and creating an environment that fosters a safe culture in the ED.

In 2007, Darryl Kirch delivered a President's Address to the AAMC entitled, “Culture and the Courage to Change.”¹⁹ In his remarks, Dr. Kirch described the “traditional healthcare culture” as one characterized by hierarchy, autonomy, individual experts, and blame. He then went on to describe the modern healthcare system and the complexity of that system, which has evolved beyond the capabilities of any individual expert. Multidisciplinary expert teams are essential for improving patient safety, as demonstrated by several recent major safety breakthroughs. The reduction and near-elimination of central line–associated blood stream infections in intensive care units across the state of Michigan,²⁰ and the impressive reduction in surgical complications associated with briefing and debriefing checklists,²¹ are only possible when physicians, nurses, technicians, and others communicate effectively and work together as high-performing teams.² Yet, most healthcare providers have not been systematically taught how to effectively communicate, particularly across healthcare disciplines. Medical, nursing, pharmacy, and other healthcare-related schools focus on clinical information and scientific knowledge, but lack a central focus on how to effectively communicate, interact, and respond to peers, patients, and other providers. This lack of a standardized approach means that graduates of different disciplines enter the same clinical care environment with different styles and vocabularies, and little knowledge about the inherent value in standardized and clear communication.²²

The author's personal experience demonstrates this point. While in nursing school, classmates and I were taught to be narrative in our communication: “think about the whole person and tell a story.” This has been reinforced by the traditional nursing edict: “nurses don't make diagnoses.” Conversely, while in medical school, fellow students and I were trained to “get to the point” or “just give the 10 second version.” Neither style is right or wrong, but they are different. Having a common and predictable structure for communication is extremely important to help navigate those differences.

Teamwork training programs and curricula have been developed to address the need for improved teamwork and communication skills among healthcare professionals. TeamSTEPPS is one model for teamwork training that is used at a growing number of institutions across the country. TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety)²³ is a widely accessible, evidence-based communication and teamwork curriculum that was developed by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD). The curriculum is organized on five key principles. Team Structure provides the framework and encompasses four key skills: Leadership, Situation Monitoring, Mutual Support, and Communication.²³ Implementation of TeamSTEPPS is intended as a system change in which providers gain specific skills that support team performance principles through designated training requirements, behavioral methods, human factors, and cultural change.

Whatever approach is used to enhance teamwork in the ED, leaders should be aware of common communication failures that too often lead to adverse events. Such communication breakdowns include providing care with incomplete or missing information; executing poor handoffs with relevant clinical data not clearly passed on; failing to confirm, or read back, information transmitted; and failing to share critical information or ask questions because of fear of speaking up.²² Effective ED leaders can help prevent these failures by setting a tone that encourages teamwork and by providing team members with some basic tools to facilitate effective communication.

Team leaders often set the tone for interactions informally, or even by default, but effective leaders understand that high-performing teams require an environment of mutual respect in which psychological safety is assured. Within psychologically safe environments, everyone is comfortable speaking up, every individual and what he or she has to say is treated with respect at all times, and disrespectful actions are not tolerated. Psychological safety is essential for effective teamwork²⁴; many clinicians become tentative or defensive when they do not feel safe, and they are then less willing to participate or contribute to the team. When team members believe that they or their suggestions are being criticized, they will stop speaking up, and they might just have the piece of information the rest of the team needs to avoid unintended harm to the patient.

Within the hectic environment of the ED, communication between individuals is often informal, disorganized, and variable. In situations where specific and complex information must be communicated and responded to in a timely manner, and the consequences of omitting critical information can be dire, such as in a code or resuscitation, it is essential to consistently add structure to the exchange. Such structures can ensure that the right information is shared at the right time with the right people. It also creates predictability as to how team members will communicate.²² Following are some specific structured communication techniques that all ED care teams should be encouraged to use.

Briefings are a critical element in high-performing teams and determine whether clinicians work together as a cohesive team or simply act as a group of individuals with different ideas and goals sharing the same space.²² Briefings quickly help set the tone for team interaction, ensure that team members have a shared mental model of what's going to happen during a process or procedure, identify any risk points, plan for contingencies, and avoid surprises. When done effectively, briefings can establish predictability, reduce interruptions, prevent delays, and build social relationships and capital for future interactions.²⁵

Debriefings. While briefings typically occur before a process or a procedure, a debriefing is a concise exchange that occurs after such events have been completed to identify what went well, what was learned, and what can be done better the next time.²⁵ It is a valuable opportunity, not often used in the ED, to determine how team members are feeling about the procedure or event, and to identify opportunities for improvement and team learning. Debriefing is also an effective venue for problem solving, generating new solutions, and positively engaging the collective wisdom of the team.²²

SBAR is an acronym for Situation, Background, Assessment, Recommendation. This structured communication technique is used to standardize an interaction between two or more people using a format that allows the receiver to anticipate the flow of information from the sender (Fig. 154-2).²⁶ When using SBAR, the sender structures the communication in the form of situation (give a 20–30 second punch line to get the receiver's attention); background (provide additional but concise, pertinent information); assessment (requires the sender to use critical thinking and define the problem); and recommendation (requires the sender to suggest a solution, no matter what his/her rank or discipline). It is imperative that the receiver respond in a respectful tone, even if the assessment is not entirely accurate, to maintain psychological safety for the sender. SBAR helps set the expectation within a conversation that specific, relevant, and critical informational elements are going to be communicated every time a patient care issue is discussed. In addition, SBAR sets the expectation that critical thinking associated with defining the patient's problem and formulating a solution occur before the receiver is contacted. Thus, both parties have a shared mental model of the flow of the conversation.²²

A closed communication loop helps improve the reliability of communication by having the person receiving the message restate what the sender has said to confirm understanding.²² A specific type of closed loop communication is a “repeat back,” which consists of four distinct actions:

1. The sender of the message concisely states information to the receiver.

2. The receiver then repeats back what he or she heard.

3. The sender then acknowledges the repeat back was correct or makes a correction.

4. The process continues until a shared understanding (a shared mental model) is verified.

When using this tool, response to a message with an “okay” or a nod is not sufficient to close the communication loop. The message must be repeated back, just as a medication order must be repeated or read back to a physician by a nurse who takes a verbal order.

Strong team performance with an emphasis on two-way communication, respect, sharing ideas, and problem solving is essential to the safe and reliable delivery of care. Not only do healthcare teams typically lack this type of interaction, but many clinicians are unaware of how poor their communication and team behaviors are.²² Training in communication and teamwork skills, though seemingly basic, is an important key to success in providing safe and reliable care to children in the emergency setting.

While senior leadership establishes patient safety aims and helps create goals for safety performance, the actual improvement work takes place at the unit level and at the bedside. Thus, it is important that emergency physicians, nurses, and staff have the improvement science knowledge and tools they need for this work to continually improve patient safety. To know if improvement efforts are working, team members will need to measure and track performance. This can be done by using metrics and data provided by the performance improvement department, or data that is collected, analyzed, and tracked directly by ED teams. Priority safety and quality metrics should be used to populate a scorecard or dashboard, with benchmarks and targets set on an annual basis to drive improvement. Safety and quality metrics should be aggregated at intervals that are appropriate for the process being measured, most often on a monthly or quarterly basis. Performance can then be compared internally, to peer groups and to best practice benchmarks as indicated.

Providing safe care to children is a priority for all members of the emergency care team. Recognizing the high-risk, highly complex environment of the ED, ED leaders and physicians need to design safety into systems, processes and practices in such a way as to lead to enhanced identification and mitigation of risk and, ultimately, prevention of harm. Patient safety requires the active involvement of individuals at all levels of the organization, including the hospital executive team and Board of Directors who acknowledge patient safety as a priority, the senior leaders and middle managers who provide training and support for front-line providers, and members of the ED multidisciplinary care team, who have the knowledge and tools needed to develop and implement strategies to reduce risk. ED physicians, who are often leaders of the care team, need to create a psychologically safe environment by setting a tone of mutual respect and modeling behaviors that encourage and support the input of all members of the team. Improvement efforts must be measured, so that progress along the patient safety journey can be monitored and tracked. Through all these efforts, ED providers can reduce unintended harm to children and provide safe and reliable care.