This is not another story about the COVID-19 pandemic, but it starts there.
In April 2020, I was an ophthalmologist deployed to work in the emergency department. Rows of tents lined the sidewalk leading to the ED entrance. We intercepted patients and ambulances as they approached the hospital for care: triage, treat or pass through to the real ED.
We simply stood outside the tents and when needed, immediately quarantined the sickest patients in specific tents.
Amid the activity, I heard the flapping sound of an unsecured tent zipper, just flailing in the wind. I stared at that flap and wondered if it should be open. After extensive preparation, will we let the virus spread through an unzipped tent meant to quarantine a patient?
Another surgeon answered that question when I looked over and saw him take time to meticulously close the tent zipper. He carried a clipboard that carried a checklist, and he continued throughout the makeshift clinic, checking zippers, securing masks and monitoring supply stations. My relief was enormous, but not because I was assured nothing bad could happen. Quite the contrary, I understood that a global pandemic brings dire consequences, but would these events be the inevitable result of the pandemic or the avoidable (and regrettable) consequence of an unzipped quarantine tent? In securing the zipper and closing that tent, I was assured of the latter.
We often say the goal of patient safety is to ensure patients receive quality care without harm. I argue that it is to deliver quality care without harm and, most importantly, without regret. A strong safety system should allow us to take risks and distinguish what was inevitable from what was avoidable. Only the highest quality safety system can do that. In the post-pandemic crush and the emergence of value-based care, we need to reaffirm patient safety as an integral component of every operation and of each person within the hospital.
A strong safety system depends on integration of standing operating procedures informed by all teams and taught to all. The elements include a reporting culture that treats safety events as information, the impacts and effects of system variables on safety events, and robust data systems that collect and report meaningful information. Much could be said about each of these, but I want to focus attention on two items that are often systematically omitted: Structural Analysis of Errors and Individual Responsibility for Safety.
Structured Analysis
It can be difficult to speak about error without evoking emotional responses such as defensiveness, aggressiveness and hurt. Passionately dedicated clinicians who find themselves close to burnout and medical moral injury are especially vulnerable to these reactions. Still, leaders must find ways to discuss error without blame but also without normalizing error.
We all recall the days when we accepted that nosocomial infections “just happened” in hospitals, but we never want to normalize avoidable harm like that again. We must build and reinforce a robust and reliable process of safety analysis. A structured system of analysis guards against subjective and ad hoc responses to errors. It takes the analysis of medical error out of the individual and places it into a system that will process it comprehensively and objectively. For example, the placement of an incorrect prosthetic can occur in high volume surgical fields. Although rare, this “never event” devastates the patient and the treatment team.
Discussing these events is critical to avoid future events. Ad hoc or unstructured analysis will overemphasize the individual, whereas a structured analysis will uniformly assess all components of the event, so the system neither blames nor placates. Let the data speak and let the process assess the event, not the individual.
Individual Responsibility for Safety
The strongest culture exists within individuals: Once you have established a robust and structured process then embrace the individual. Our safety systems should envelop the goals of each individual in healthcare. That is, safety should not be a discrete goal, it should be a part of every goal, both tangible and intangible. In an increasingly complex healthcare system, individual work moves well beyond “Do No Harm” into “Do Not Let Harm Happen.” When everyone understands (and can speak to) their critical role in patient safety, and when individual actions are supported by a high-functioning and fair culture, your system is safe.
In healthcare, there is no elimination of risk and no assurance of good outcomes, but there is a way to avoid regret. Create a safety system that is reliable, meticulous and ubiquitous. It will gain the deserved trust of your patients and amplify the dedicated effort of your providers.
Thomasine Gorry, MD, served as vice chair, Quality and Safety/associate dean, Continuing Education, Perelman School of Medicine, University of Pennsylvania, and now works in pharmacovigilance branch of the pharmaceutical industry.