Report patient safety lapses in your hospital

CMs can help eliminate careless behavior

Hospital case managers are involved with patients from admission through the entire episode of care and discharge, which puts them in a position to spot patient safety issues and work on ways to prevent them, says John Banja, PhD, professor of rehabilitation medicine, medical ethicist at Emory University's Center for Ethics and director of the Section on Ethics in Research at Emory's Atlanta Clinical and Translational Science Institute.

"Since case managers observe patients during the entire hospital stay, patient safety has got to be an integral item on the case manager's radar screen. When lapses of safety occur, case managers are among the most likely people to pick up on it," he says.

As the Centers for Medicare & Medicaid Services (CMS) moves toward denying reimbursement for hospital-acquired conditions that can be prevented, with commercial payers likely to follow suit, it's more important than ever to eliminate careless behavior by the staff who are providing care, Banja points out.

The first rule of health care ethics is to do no harm, he says.

"If we have elements in our system that expose patients to an unnecessary level of harm and we're not doing anything about it, we are breaching our ethical obligations," he says.

Hospitals are very complex organizations, and if there is just one glitch in an entire process, it could result in a patient safety issue, Banja says.

For instance, dozens of people are involved in the processes that take place between the time a physician orders a medication and the time a patient receives it.

If a patient doesn't get his or her medication on time or gets the wrong medication or dose, it could be that the doctor's handwriting was illegible, that the pharmacy issued the wrong medication or dose, that the nurse failed to administer it on time, or other scenarios.

"When the glitches occur, nothing bad happens the majority of the time, but that can seduce us into thinking the system is safe enough. Then out of the blue, a patient gets the wrong medicine and a catastrophe occurs," he says.

The health care system has a tendency to tolerate a lot of imperfections, as well as tolerating people — especially physicians — who are known to be careless, Banja says.

In addition, clinicians often have to treat patients when information is missing from the medical records. Equipment may not work properly or a clinician routinely fails to wash his or her hands between patients.

"These kinds of things happen, and sometimes we don't take steps to correct them as aggressively as we should," he says.

Most nurses on the unit know which nurses are pulling their weight and which ones tend to take short cuts in patient care, he adds.

"Health professionals, especially nurses, understand that they work within an imperfect system, and they're always putting Band-Aids on those imperfections. The problem is that while nurses are unsung heroes and heroines who can get the job done under extreme circumstances, they are not especially good at coming up with long-term fixes," he says.

Most hospitals are very good at short-term fixes for system problems that occur, but they fall short when it comes to making permanent changes in hospital processes to eliminate errors, Banja says.

For instance, when a case management director reviews data, he or she may notice a spike in urinary tract infections or central line infections. This could be the impetus for a quality improvement project, first to determine the cause of the increased infections and then to take steps to correct the problem, he says.

"Most patient safety issues do not tend to be dramatic things like wrong-site surgery. They generally tend to be the more mundane things that people overlook and omit doing," he says.

Look for patterns, Banja says.

"People make errors. It's when there is a pattern of these errors happening that you know something is systemically wrong," he says.

For instance, one observational study of physicians showed that more than a third miss one of the five basic steps in putting in a central line, Banja says.

"Health care providers need to develop checklists like airline pilots have been using for decades. The checklist should include the basic steps that a provider checks off each time the procedure is performed," he says.

When health care professionals fail to follow hospital policies and procedures or basic standards of care, it's not because they're evil or malicious. It's usually because they're overwhelmed with work, he says.

"We should not be pushing health care providers to their limits of endurance. Sooner or later someone who is so exhausted by overwhelming pressure to do more and more is going to make a big error," he says.

When an error occurs, the immediate response shouldn't be to blame or punish the person responsible but to determine what made it easier to commit the error, to forget to do something, or to overlook something important, he adds.

Hospitals should have a mechanism for addressing patient safety lapses when they do occur, Banja says.

The policy should spell out what a staff member should do if he or she observes a patient safety issue and should include a mechanism that protects the person who reports the lapse or carelessness, he says.

"Overwhelmingly, people do not like to point the finger at another person. Hospitals must establish patient safety policies that emphasize that staff members should report patient safety lapses," he says.

In addition, hospitals must respond when patient safety problems are reported.

"It really boils down to leadership. Leaders all say they're concerned about patient safety, but they must constantly and relentlessly practice what they preach," he says.

[For more information, contact: John Banja, PhD, medical ethicist, Emory University's Center for Ethics, e-mail:]