Key Point

Improving safety in the ICU requires improved communication, teamwork, a blame-free environment, and leadership involvement.

PHOENIX—Everyone makes mistakes. The truth of this statement is undeniable, yet the medical community has often been unwilling to acknowledge it. At this year’s annual meeting of the Society for Critical Care Medicine, Peter J. Pronovost, MD, PhD, Associate Professor of Anesthesiology and Critical Care Medicine, Surgical Health Policy and Management at Johns Hopkins University School of Medicine in Baltimore, led a discussion of ways in which ICU personnel can improve communication and decision making, create a blame-free culture, lessen the chance of errors, and learn from errors if they occur.¹

MISCOMMUNICATION

In the ICU, patient data presentation usually consists of handwritten—often illegible—notations on a single sheet of paper, the location of which is not always known. Obviously, a different system would be easier to work with, but how can it be implemented? What should it include? Michael J. Breslow, MD, a former intensivist now with Visleu, Inc (an information technology company in Lutherville, Maryland), described the need for the presentation of data in a form that can be understood more efficiently and effectively.

“Most communication in the ICU is verbal,” Dr. Breslow pointed out. “So you are dealing with one-on-one interactions, handwritten notes, and scribbled to-do lists.”

Clinical information systems can ensure that patient data are available and presented in a legible, consistent format. Data can be grouped by organ system, using color-coded charts and graphs to flag abnormalities, said Dr. Breslow. This can help identify what’s going on with the patient in a rapid, easily understood fashion.

“A number of electronic systems can provide information as a reference tool, but the best would probably be some kind of alert system at the patient’s bedside,” Dr. Breslow noted. The capabilities of such a system would include flagging drug allergies, interactions between medications, and appropriateness of dosage range, for instance.

AN ICU CULTURE WITHOUT BLAME

Several speakers pointed out that in other high-reliability industries (eg, aviation and nuclear power) safety-alert systems are built-in. Victoria J. Fraser, MD, a Professor of Medicine in the Department of Infectious Diseases at Washington University School of Medicine in St. Louis, suggested that “errors could be prevented by redesigning health care delivery systems rather than blaming individual practitioners.

“We have held ourselves to really excruciatingly high expectations of perfection,” she added. Blame and punishment for errors have been reinforced, leaving the individual with nothing but admonitions to try harder or learn more. Complex analyses of single errors are not as helpful as the systematic evaluation of large numbers of errors would be, she said. “The standard recommendations to enhance patient safety should be to try to fundamentally assess and improve the culture so that it focuses on safety, to increase reporting of errors and promote discussion and analysis of errors, and then institute new systems to prevent errors.”

How do you improve teamwork and communication? Nonpunitive, confidential, independent reporting systems can help, but there are barriers. These include uncertainty about what to report, failure to recognize that errors have occurred, inadequate feedback from supervisors, and lack of positive reinforcement for identification of errors. In addition, fear is a factor. This includes fear of blame, repercussions, labeling, and negative consequences for the patient. “We need to start to change the culture to help people recognize that it’s valuable both to talk about errors and to look for them,” Dr. Fraser said.

At her hospital, Dr. Fraser studied the use of the SAFE (Safety, Action, Focus, Everyone) reporting card. The reporting card, which encourages health care workers to report near misses and no-harm as well as harmful events, increased reporting of medical errors almost eightfold to ninefold in multiple ICUs—and did so in a nonanonymous nature.²

GET TALKING

During an Agency for Healthcare Research and Quality patient safety evaluation, Bradley A. Evanoff, MD, an Associate Professor in Washington University’s Program of Occupational Therapy, asked personnel from a number of different medical and surgical floors and ICUs at Barnes-Jewish Hospital in St. Louis to complete a questionnaire. The questions were simple:

• Was the doctor able to name the nurse that day?
• Did the nurse know the doctor’s name that day?
• Had the doctor and nurse spoken to each other at all that day?
• Did they have any overlapping clue about what the goals were for the patient?

The responses to the questionnaire were surprising to everyone. They also highlighted a major contributor to the quality of patient care—communication.

Only 13% of doctors and nurses were in full agreement about the day’s goals for the patient. In a third of responses, there was no overlap in agreement. If the doctor could name the nurse, then there was a much higher likelihood that they were going to agree on the priorities for that day. Likewise, agreement was higher if the doctor had spoken to the nurse.

Concordance of priorities for a patient’s care was linked to the frequency of communication. The lack of consistent verbal communication between caregivers was likely to impair patient care.

TEAMS INSTEAD OF HIERARCHIES

Dr. Fraser pointed out that the traditional hierarchical structure of the hospital has to be broken down into teams to address safety. Small groups rapidly develop cohesiveness and trust.

In addition, senior leadership must be involved and enlisted to support these changes. “Otherwise,” said Dr. Breslow, “it’s an uphill battle.” Leaders will have to demand that the medical community rise to serve patients better collectively, agreed Timothy Buchman, PhD, MD, Harry Edison Professor of Surgery at Washington University Medical School. “That kind of top-down leadership has to be in place for the type of progress we’re talking about,” he stressed.

“We have to try to standardize what we do, create independent checks for our key processes, and then learn when things go wrong. Unless you have a culture of safety, it’s impossible to reorganize care,” concluded Dr. Pronovost.

—Gale Jurasek

References
1. Pronovost P. Re-engineering the ICU to provide a safer environment. Presented at: annual meeting of the Society for Critical Care Medicine; January 17, 2005; Phoenix, Ariz.
2. Osmon S, Harris CB, Dunagan WC, et al. Reporting of medical errors: an intensive care unit experience. Crit Care Med. 2004;32:727-733.

Return to table of contents