Opinion | Clinicians Aren’t Always to Blame for Medical Errors

It’s no exaggeration to assert that hospitals can be hazardous to your health. Medical errors are the third leading cause of death in the U.S., according to a 2016 report in the The BMJ. Such misfortunes violate the cornerstone precept of the Hippocratic Oath: do no harm.

I have been a hospital CEO for the last 29 years, and before that I was a nurse on the front lines of care. In that time, I’ve learned an important truth: organizational culture can prevent unnecessary medical errors.

Yet, most hospitals have proven slow to adopt a framework that can prevent such adverse events from happening, or at least minimize the probabilities. This process is generally known as high-reliability risk analysis.

Instead, many hospitals continue to rely on troubleshooting as they work. These hospitals and health systems, in adopting a reactive problem-solving methodology, run the risk of inviting unfortunate consequences. These range from lower-quality healthcare delivery and unfavorable patient outcomes to workforce shortages and financial instability.

Sectors outside healthcare pioneered the concept of high-reliability organizations. As a result, high-reliability is often applied as the norm everywhere from space flight command centers and nuclear power plants to naval aircraft carriers and oil and gas refineries. These extremely hazardous industries implemented this promising process expressly to lower safety risks enough to eliminate or minimize catastrophic accidents caused by human error. By and large they have done so successfully.

Logic dictates that the healthcare system can — and should — apply high-reliability to patients without further delay.

Consider the rationale here. Like the aforementioned industries, hospitals function in intensely complex, demanding, heavily regulated settings. The pressure to perform with consistent excellence is nonstop and all-consuming. Risks are high, and so is the pressure to quickly reach smart decisions that could spell life or death. The margin for error is thin.

Hospitals are increasingly making progress in improving clinical practices for safety, but more is needed. Of course, it can be challenging to change and improve processes and incorporate safety principles into an entrenched hospital culture. Even with hospital leaders committed to change, such reforms can be tough to prioritize and never happen overnight.

“Despite serious and widespread efforts to improve the quality of health care, many patients still suffer preventable harm every day,” a breakthrough 2013 study from the Joint Commission Center for Transforming Health Care explained. “Hospitals find improvement difficult to sustain, and they suffer ‘project fatigue’ because so many problems need attention. No hospitals or health systems have achieved consistent excellence throughout their institutions.”

We’ve worked hard to make our hospital an exception.

Several years ago, we began a high-reliability journey. But like most other hospitals that decided to do the same, we practiced it piecemeal (other than a shared foundational framework). Some departments followed the methodology, while others acted independently. But because of the variables across the organization, it was difficult to sustain the successes gained in narrowing the risks to patients.

But then the COVID pandemic hit, rapidly changing the equation for healthcare safety and suddenly raising the standard for crisis control. This once-in-a-generation catastrophe motivated us to revisit our safety reporting structure. In fall 2021, we invested in training the entire team in high-reliability methodology and revamped our policies and processes hospital-wide. We went full-scale with high-reliability, incorporating it into our infrastructure and into our organizational DNA. It was systemic, wired into everything we do, across every department, and practiced continuously.

We implemented a precise internal risk analysis process called collaborative case reviews, designed to promote and improve patient safety. We launched new initiatives, including a daily safety huddle. In the huddle, 50 or more leaders join a call to give a safety status update from every part of the hospital. What are the potential risks we have identified? What is lurking under the surface that we should know about? Are we taking adequate steps to address any problems? It is conducted briskly, running under 15 minutes. We launched Executive Safety walk rounds, where our senior leaders meet with frontline staff, in person, for the same purposes. We built our safety reporting system into a risk register to track organizational patterns and issues.

Result: we increased safety event reporting by 50%.

What changed at our hospital is this: We established high-reliability as an everyday practice, living and breathing it. In reinforcing the safety culture in our system, we rebuilt trust among frontline staff and, as a direct byproduct, decreased blame and finger-pointing.

Over time, our nurses felt freer to report safety issues. At first, they would report an issue only after the fact, once a problem reached a patient. But later, they also would report near-misses, such as a delay in treatment, where something that should not happen almost happened — and, equally as valuable, could happen again. Learning about potential problems matters at least as much as learning about existing problems. We then gain the opportunity to act preemptively rather than retroactively.

We also coached staff to develop the habit of reporting an issue each time it cropped up, rather than doing so only once and perhaps later feeling the need to say to an administrator, “But I told you once already.” This consistency makes a difference. The higher the reporting volume, the better we can detect the presence of risk in the system. Patterns of recurring issues became more visible, and we could measure the effect of corrective actions by decreasing specific events.

A case in point: a staffer reported a problem with our transfusion IV set in oncology. The manufacturer, in response, blamed human error. But staffers kept reporting that the problem had persisted. It appeared to be no one-time aberration, but a regular occurrence — a flaw not in staff training but in product design. We went back to the manufacturer armed with data. The manufacturer acknowledged the issue and redesigned the set to eliminate the flaw. This outcome created a ripple effect, benefitting hospitals across the country that rely on the same product.

Admittedly, none of these changes were easy to make, nor will they be easy for other institutions. But it is possible. We have found that high-reliability is essentially a management philosophy. To cultivate a culture that values safety above all, you must maintain an unwavering focus on communication, coordination, and collaboration among staff. It must go above and beyond freestanding safeguards such as hand-washing procedures or fall-prevention programs. In short, it must be systemic rather than incremental.

Only if all health systems move in this direction, whether step by step or in a single bold leap ahead, can any of us ever expect to achieve the ultimate aim of zero harm to patients.

Christine Schuster, RN, MBA, is the president and chief executive of Emerson Health System in Concord, Massachusetts.

Please enable JavaScript to view the comments powered by Disqus.