Change is constant. Change is challenging. Some changes, like the five rights of medication administration, surgical timeouts, and clinical pathways, are compulsory. Changes are often identified when something fails. A traffic light becomes a permanent fixture at an intersection where accidents or a loss of life happen. A new protocol is enacted when a fatal error occurs. Awareness drives change and safety initiatives in health care.
I recently attended a mandatory seminar to kick off my institutions newest initiative: Zero Harm. The presenter opened by talking about highly reliable organizations (HRO) like aviation and nuclear power. These organizations are attentive to the possibility of failure and have safeguards and safety checks to ensure that errors don’t happen
My three takeaways from this presentation were:
- High-risk situations have an increased chance for error. Yet nuclear power, European railroads, and scheduled commercial flights have far less errors than healthcare.
- Most serious patient harm events are a result of a systems failure. People make mistakes but systems can make some mistakes nearly impossible. For example, you can’t put leaded fuel into an unleaded car. Why? Because the openings to each gas tank are specifically sized for the correct fuel nozzle preventing people from mistakenly putting the wrong fuel in their car. Healthcare is making similar safety changes.
- Delay in diagnosis and treatment is a number one safety event, twice that of falls, and nearly five times more common than wrong patient surgery. I was recently working on a case involving a delay in insurance approval for a port-a-cath. Despite talking with the oncologist, schedulers, and myself, no one asked if the patient was on blood thinners. The issue at hand was getting approval; once that was done the patient was finally asked this important question. I felt horribly responsible, after all I am a nurse, and nurses think about those kind of things. Right?
Zero Harm is not without opponents suggesting the impossibility of “zero." However, the well known Hippocratic oath reads: First, do no harm—not do little harm.
High-risk situations coupled with high-risk behaviors (e.g., work arounds, inattentiveness, disregard, assumptions) increase the likelihood of a serious safety event. Delivering chemotherapy is a high-risk situation requiring low-risk behaviors (e.g., checking medications, questioning unclear orders, asking for help when needed).
What changes have your institution enacted to keep patients and staff safe? Are there any changes you can make in your day-to-day practice to ensure that no one is harmed on your watch?