The trusted source for
healthcare information and
Culture change and ‘red zone’ improve patient safety
A hospital in Casper, WY, has reduced medical errors by changing the staff culture about patient safety and by instituting a system that notifies others when a staff member is involved in a high-risk task and should not be interrupted.
Wyoming Medical Center’s effort to improve patient safety kicked into high gear in 2009, says Risk Manager Shawna Willcox, CPHRM, MBA. Three years later, the hospital saw a 70% reduction in errors that cause serious harm to patients and a corresponding improvement in malpractice costs, she says.
The hospital worked with a consultant, Craig Clapper, PE, CMQ/OE, founding partner and chief knowledge officer of Healthcare Performance Improvement in Virginia Beach, VA. Together they reviewed sentinel events and other errors.
“We found that we weren’t as safe as we thought we were, once we looked at the hard data,” Willcox says. “We were not unsafe on the national average numbers, but we were just average. We thought we should do better and do something different.”
One of the first tasks was to conduct individual interviews with staff members to ask what was wrong with patient safety at the bedside. The interviewers sought specific information about processes and procedures that did not work, for example, and the workarounds that staff actually used. That information was enlightening, Willcox says. “Based on that information we pulled 65 people, mostly bedside staff but a few managers, to an off-site retreat,” she says. “During that retreat, we determined what our safety behaviors needed to be and what safety or error prevention tools we needed to use. One thing we learned is that our communication was not good.”
Communication breakdowns were tied to about 85% of all errors, Willcox says. Working with their consultants, Willcox and her colleagues instituted some changes designed to improve communication. One is the “three-way repeat back,” which is similar to the familiar “two-way read back” used when a nurse is receiving orders over the phone — but with one more step.
The three-way repeat back can be used over the phone or in person. One person gives the instructions, the second person repeats those instructions, and the first person confirms that it’s all correct. Requiring an affirmative confirmation in that third step, as opposed to just not objecting, means the first person must listen to what is being said, Willcox explains.
The patient safety improvement effort was spurred partly by a tragic medication error in 2007 that resulted in the death of a child, Willcox says. In that case, a nurse mistakenly gave one child’s morning medications to another child. Afterward, the confusion was traced back to the nurse being distracted by other staff.
The hospital also encourages staff to nurture a “questioning attitude,” Willcox says. Reviews of past errors revealed that there almost always was someone in the room who suspected something was not right but didn’t speak up.
“When things are going south and you think something is wrong, we tell our people that you have to speak up, you absolutely must voice your concerns,” she says. “I believe that is a huge tool. When I teach new staff and retrain existing staff, I tell them over and over again that if a question pops into their brains, they have to ask it and make sure they receive an answer.”