Patient safety often is about more than errors

A recent incident in which a surgeon allegedly arrived drunk for a procedure illustrates an important lesson about how broadly risk managers should educate staff about the concept of patient safety, says one expert. Does your institution’s culture encourage staff to speak up and "stop the line" when they sense someone is not in the proper frame of mind to care for patients, or do you focus entirely on tangible errors such as incorrect dosages?

Any effort to improve patient safety must include a broad range of scenarios and empower staff to act when it thinks unsafe conditions exists, says Geri Amori, PhD, ARM, FASHRM, president of Communicating HealthCare, a risk management consulting firm in Shelby, VT, and past president of the American Society for Healthcare Risk Management (ASHRM). It is a mistake to think that patient safety is all about medication errors and other easily defined "errors" that might be caught before they cause harm, she says.

Tragedy also can be averted by realizing that individuals sometimes are just not in the proper state to care for patients, Amori says. Sometimes that condition will be caused by something as grievous as being under the influence of alcohol or drugs, she says, but it also may related to the individual’s emotional state.

"In a culture of safety, everyone must be empowered to stop a situation that could endanger the patient. Everyone must be able to stop the line, as they say in manufacturing," she says. "We usually talk about errors, but we don’t often talk about it in terms of someone being able to perform the services they’re supposed to provide."

Staff report suspicious surgeon

One example is the recent case from the Boston area, where orthopedic surgeon Robert M. Caulkins, MD, is accused of showing up for surgery while under the influence of alcohol. Staff at Caritas St. Elizabeth’s Hospital in Brighton reportedly became concerned when the surgeon appeared to be under the influence while preparing for a procedure, according to information from the state Board of Registration in Boston. The procedure was canceled for unrelated reasons, and no harm came to the patient.

Hospital spokesman Carl Foster confirms that Caulkins no longer has privileges at Caritas St. Elizabeth’s. The hospital’s procedures for reporting such staff concerns worked appropriately, Foster says, but hospital officials declined to elaborate. Amori says the incident is a good example of how staff members may be faced with situations in which they must feel empowered to speak up.

"It could be a nurse who is emotionally upset about something at home, or a doctor who is distracted by another case, or anyone who is under the influence of alcohol or drugs. We’re talking about anything, really, that takes your mind off of caring for the patient," she says. "We have to teach people that these problems can be just as dangerous as something more tangible like picking up the wrong syringe, and we have to encourage people to do something about it."

The problem, of course, is that the nurse who is upset about a problem at home or the doctor who is thinking about another difficult patient is more likely to pick up the wrong syringe, for example. Addressing the clinician who isn’t in the right of state of mind can be a way of preventing errors even earlier, Amori notes.

"That person is a walking time bomb," she says. "The chance of that person making an error is very high."

But staff aren’t likely to speak up when it is concerned, unless the institution has a strong culture of safety that assures them they won’t be punished for voicing their concerns. There is a natural desire not to challenge co-workers, and especially authority figures like physicians, when they seem to be unfit for duty. Patient safety education must explain that it is important to take action in these difficult moments.

Teach staff how to speak up

How? Amori suggests encouraging staff to follow these steps:

1. Consult a colleague to confirm your concerns. Discreetly ask someone else who is present if he or she has the same concern. Confirmation can help avoid misunderstandings and overreaction, while encouraging further action if necessary.

2. Talk to the person in question in a supportive way. The staff can go to the person and express concern, offering help without making accusations. One nurse might say to another, "Mary, you just don’t seem yourself today and I’m concerned that something could happen that you’ll regret. Maybe you could use a day off?"

The key at this point, Amori says, is to keep the conversation supportive and nonconfrontational. Don’t blurt out anything like, "You’re a danger to the patient and too messed up to do your job today." That will only make the subject defensive.

3. If necessary, the concerned staff must be able to contact a senior administrator immediately. Exactly who this contact will be can depend on your organization’s particular structure, but it should be a top leader in the hospital, such as a vice president. Going through the chain of command by contacting the immediate supervisor and working on up is not sufficient, Amori says. That can result in the concerns being bogged down in bureaucracy.

"When someone’s concerns are serious enough that they need to stop the line, they need to speak with someone with the authority to make it happen right then," she says. "But this only works if there is a culture in place that assures those concerns are taken seriously and that there is no fear of punishment for speaking up. They also need to know that the impaired person is not going to be fired summarily but rather will be dealt with humanely."