Barbara Olson, Nurse, Other Clinical, 09:43AM Sep 19, 2010
Last week the New England Journal of Medicine published an interesting commentary about safety in ambulatory care settings (Patient Safety beyond the Hospital), comparing issues and outcomes with those in acute care facilities. The authors note that the safety infrastructure is less developed in physician practices and clinics than it is in acute care facilities.
This reminds me of events reported to and shared by ISMP, especially those involving combined diptheria, tetanus, and pertussis vaccines formulated for two very different patient populations: very young children (who need to develop primary immunity) and older people who simply need a booster. With nomenclature like DTaP and Tdap, who wouldn’t predict mix-ups, especially in care settings that serve people across the life span. Have you ever been in a clinic where, “We need a crackle/static/loss of signal/more crackle static shot in Room 7″ is a routine call-out? Chances are you’re seeing good people using weak processes to deliver care.
Safety analysts and cognitive psychologists call practices like the one I’ve described “normalized deviance.” Processes are entrenched in a dysfunctional fashion to such an extent that reasonable people cease to perceive they’re risky or wrong. If you’re familiar with Outcome Engineering’s “Just Culture” algorithms, practice norms like the “crackle/static/loss of signal/more crackle static shot in Room 7″ would likely be categorized as “at-risk behavior.” Clinicians who engage in at-risk behavior do not intend harm but nevertheless choose to engage in risky practices, erroneously believing their choices are safe and sufficient.
When the NEJM authors talk about the lack of safety infrastructure, it’s tempting to think they mean lack of regulatory oversight. But it’s also helpful, I think, to translate identified deficits into behavioral expectations that can become norms (“the way we do things around here”), known and embraced by all healthcare professionals. These are things that can be taught to clinicians as part of safety science in basic professional school curricula. Nurses, pharmacists, and doctors need to learn the “science behind the compliance” and know why safety measures are not things that satisfy surveyors, but rather save patients.
Licensed clinicians who oversee individual plans of care as well as the practice of unlicensed assitive personnel need to know specific facts. Like how written orders, preferably entered into a computer, trump the accuracy of verbal orders. We need to be taught the value of meticulous read-back and verification, when verbal orders must be given. The rationale for syringe labeling and how reliabilty is impacted by the behavorial choice to “label” or “not label.” And we need to learn these things in context, from real-world examples showing what happens when good intentions are not supported by well-engineered processes.
The NEJM article talks about other compelling issues in ambulatory care. Take a look and feel free to leave a comment, from your personal or professional experience in ambulatory care.