Failure Recovery Tool Offers Guidance Amid the ‘Chaos and Shock’ of Medical Errors
This article appears in the March issue of Patient Safety Monitor.
Hospitals need to have a structure in place to respond to patient safety failures
Healthcare can be a stressful industry to work in, particularly when something goes wrong. Instead of relying on humans to react under pressure, one organization is offering a structured approach to patient safety failures.
In January, LifeWings Partners LLC, an organization that specializes in patient safety training and best practices, released a failure recovery tool aimed at standardizing the way hospitals respond to medical errors. Patient Safety Monitor Journal spoke with Stephen W. Harden, chairman and CEO of LifeWings in Collierville, Tennessee, about the new tool and how hospitals can integrate it into their patient safety systems.
Editor’s note: The following has been edited for space and clarity.
Q: Can you tell me why you decided to focus on failure recovery?
A: Despite their best efforts, there is a lack of perfection on the part of healthcare. Healthcare is provided by humans and one thing we know about humans is they are going to make mistakes. So it’s not perfect and the mortality statistics point that out.
Q: Why do clinicians deviate from protocols?
A: There are basically four reasons why a protocol isn’t followed:
One reason is people don’t know the protocol exists because they’ve never been taught it. That’s a training problem.
Some people have been taught that there’s a protocol, but they don’t actually know how to follow it. Teaching means that you’ve told them how to do it and explained the importance of the how and the why. Then you have an expert demo how to do it. Then the learner practices it under the watchful eye of the expert?they actually try and do the protocol. And then the learner gets feedback from the expert.
The third reason healthcare professionals don’t follow protocol is they can’t. There is some sort of barrier the organization has left in the way. Maybe the protocol is written down, but the manual is hidden away in someone’s office. So you’ve added too many steps to the healthcare provider’s workday to go get the protocol and follow it. More commonly the reason they can’t is they are physiologically not capable of following it. What that means is you’ve mis-hired somebody. You’ve hired someone that can’t adequately do the job.
The fourth reason is they are making a conscious decision not to. Typically, that’s because they think their way is better or that it’s not really required. If you think your way is better, or you feel like you can combine some steps to make the protocol more efficient. Or you don’t have time to do it that way and you’ve developed a shortcut. There are all sorts of logical reasons on the part of the provider where they think, “I really don’t have to go through all these steps?there’s a quicker, smarter, easier way to do this.”
Quite frankly, that is really the main reason protocols are not followed, and the problem that managers and supervisors within healthcare struggle with the most is willful noncompliance.
Q: How does the checklist help with that? How does it identify which of these reasons led to failure and help resolve willful noncompliance?
A: I’m not sure it helps any of those reasons. What it does do is it acknowledges the fact that humans do make mistakes despite their best efforts. In that moment?when you realize you’ve made a mistake and you need to recover from it?you really do need a blueprint or a checklist to follow, when maybe you’re not cooking on all cylinders. When a mistake has been made and you’ve hurt someone you didn’t intend to hurt, everyone is in a state of mini shock. You need a guideline to follow to help plot your steps forward in the midst of the chaos and the shock. And that’s what it’s for.
The analogy for this is a flight crew on a commercial airline 30,000 feet above the ocean and three hours from nearest landfall, and they have an engine fire. Well, that’s going to create a lot of shock and consternation in the cockpit; I don’t care how experienced the crew is. You don’t want them to try and use all their cognitive abilities to come up with how they are going to respond to an engine fire 600 miles from nearest landfall with 235 people on board. You want those steps laid out for them so, in the midst of this mind-numbing shock, they don’t have to depend on their cognitive abilities when under so much stress.
It’s the same sort of analogy. You hurt a patient who put their life in your hands. Your job was to fix them and now you’ve hurt them. There’s a lot of stress. We’re not at the top of our game cognitively. Having a checklist to follow that guides you through these steps in the midst of that performance detriment is really valuable.
Q: Is that why hospitals struggle? Because they don’t have that structure in place?
A: I don’t know. I can say they don’t have recovery protocols in place, but it’s probably not as well-defined as a protocol to deal with a bloodstream infection or a protocol to deal with ventilator associated pneumonia.
What we’re trying to do is give high-performing teams in hospitals a checklist to follow to guide them through that high stress high workload moment after they realize they’ve hurt a patient.
Q: You’ve listed nine steps in the failure recovery tool. Are any of those particularly important or ones that hospitals tend to neglect?
A: If you pinned me down and made me pick one, I would say most hospitals struggle with acknowledging throughout the team that something was amiss and confronting it head on. There’s a culture of silence, both because no one wants to admit a mistake, number one, and number two, they don’t want to get sued.
This is less so now in my career helping hospitals than it was 10 years ago. Ten years ago, I was always shocked at the culture of silence that pervaded around a mistake. That’s one of the primary ways we learn?acknowledging something you didn’t want to happen happened, understanding why it happened, and disseminating the learning. That’s an area of healthcare that’s way, way behind aviation. Aviation is really good at picking at its scabs and figuring out why that happened, sharing lessons learned, and letting others learn from your misfortunes so they don’t repeat the mistake. Healthcare is not there yet.
Q: But you feel that has shifted over the last decade?
A: I do believe there is a groundswell or shift happening slowly but surely. But they certainly aren’t where aviation is in terms of publicizing and acknowledging their mistakes so everyone can learn from them in a nonpunitive environment.
Q: How would you like to see hospitals use this tool?
A: Here’s what I want them to do: I want them to say, “Yes we need something like this. This is a good start. Let’s blow this up and build it for our specific purposes.”
I’d like to see them use the underlying principles and customize it to their needs. Quite frankly, that’s the only way anyone is going to use it. The one thing we’ve discovered about all the protocols we promote and offer to all of our client hospitals is they have to take those and blow them up and rebuild that in their own vision and culture and their own way.
If you build something yourself and it fits your people and culture and your particular medical society, you’re way more likely to use it than if someone just handed it to you and said, “Here, use this.”
This article appears in the March issue of Patient Safety Monitor Journal.