What is new in critical illness and injury science? Patient safety amidst chaos: Are we on the same team during emergency and critical care interventions?

More than a decade ago, the Institute of Medicine released its famous report To Err Is Human, which set an ambitious agenda for the world to reduce the number of patients harmed by medical errors.[1] In response, a number of new initiatives were launched, including electronic medical records, limited resident and faculty work hours, and implementation of evidence-based care bundles and checklists.[2] Additionally, federal entities such as the Agency for Healthcare Research and Quality established funding for patient safety research helped to develop patient safety organizations and a set of nationally vetted Patient Safety Goals via the National Quality Forum. In short, much of this work was focused on mitigating the risk of the human element in chaotic healthcare environments.[3] The current issue of the International Journal of Critical Illness and Injury Sciences focuses on complications associated with procedures performed in the intensive care and trauma setting.[45678910] It is imperative that all key aspects of patient safety should be maintained and observed during any routine and non-routine invasive procedures, especially those performed outside of the standardized, controlled environment of the operating room.

In 2005, the Patient Safety and Quality Improvement Act was signed into law to promote confidential reporting of adverse events and improved communication between providers. This led to a paradigm shift recognizing that most patient injuries are the results of system failures, not medical negligence.[11] While this act was intended to address communication barriers, current strategies remain focused on redesigning “system processes” to ensure safe care.[12] A significant part of this system is the human element and indeed human factors in both elective and emergency procedural situations are a reality. We have embraced our innate human traits to quickly analyze and adapt to challenging situations, which is aptly referred to as human resilience. Current patient safety efforts must focus on redesigning system processes and facilitating communication to channel human resilience toward improved patient outcomes.

New methodologies and strategies, such as checklists, team training, and simulation are modalities that when used appropriately, can complement human resilience, and as a result may successfully mitigate patient risk and ensure the best outcomes possible. These strategies have been identified as best practices at high-performing organizations yet we have likely underestimated their impact.[13] Team training using crew resource management theory from aviation has been adapted into the health care system,[14] The Veterans Health Administration, the largest integrated health care system in the US implemented a national operating room team training program and studied the outcomes which revealed reduced mortality.[15]

Team training, as it currently exists in our operating rooms, relies heavily on checklists and effective care transition communications. The use of these checklists has been shown to globally reduce morbidity and mortality as made evident by the World Health Organization's Safe Surgery Save Lives program.[16] Since this seminal publication, the safe surgery checklist, as popularized by Dr. Atul Gawande, has spread from the operating room to every aspect of patient care. Dr. Pronovost's success in reducing central line infections to almost zero in Intensive Care Units using a standardized checklist is another prime example of a hardwired “safety tool” aimed at improving care.[17]

The implementation of checklists and standardized processes around the care of patients has been pivotal to develop a strong culture of safety and team-based care.[16] Treatment-specific checklists regarding care as fundamental as oxytocin administration that are implemented by care teams have been shown to not only decrease cesarean delivery rates but ultimately improve neonatal outcomes.[18] With outcome data now supporting checklist use, they have proven their worth in leveling the playing field across a broad range of elective or emergency situations. They enable every member of the team to feel valued and enable them to express concerns when necessary to positively influence outcomes.[18] Ultimately, the use of checklists is completely dependent on the collaboration of all healthcare providers; the entire team has to be engaged and cognizant that the checklist tool is intended to drive safe behaviors.[12] Despite occasional arguments to the contrary, procedural checklists are both productive and non-disruptive, and as such should be fully embraced by the traumatologists and intensivists alike.[19]

Along with checklists, facilitating communication is another integral element of team training. Interprofessional conflict between nurses and physicians is widespread, and both groups can have very disparate perceptions on team dynamics. Obstacles such as differing expectations of relationship power, perception of loss of autonomy, role ambiguity, and professional cultural differences make communication training vital to the success of a team. Understanding the role of suboptimal communication in sentinel events, as well as the diverging perception of teamwork, especially high-risk situations such as those encountered by physicians and nurses, it is much easier to recognize that the “neglected dyad” is the physician-nurse pair.

It would, therefore, appear that as a surgical community, we may have come 360° from attempting to eliminate human factors and overcoming them with standardized processes and technological advances to addressing them head-on. We have borrowed from other industries such as business and applied Lean and Six Sigma principles so to improve process and efficiency.[2021] Our knowledge of rare occurrences such as retained foreign bodies, including natural history and intraoperative safety omission or variance (SOV) profile, was limited. A recent study found that most operations complicated by retained foreign bodies were found to involve team/system errors and two or more SOVs. Therefore, the emphasis on team training is key.[22] Similarly, the retention of intravascular foreign bodies, although a sentinel event, is a potential reality every time a central line is placed. Unexpected procedural factors and equipment failure are significantly associated with intravascular retained foreign bodies and over half of all retained intravascular items are missing confirmatory postprocedural imaging. This further emphasizes the requirement for strict adherence to established protocols and stringent radiographic review for intravascular procedures to prevent such safety event occurrences.[23]

The environment we work in is no less than chaotic. Every procedure we perform has the potential for a complication or a patient safety event. We perform bronchoscopies, chest tube insertions, central line insertions, tracheostomies, and pericardiocentesis, etc., on a daily basis. Additionally, our patients, particularly in the acute care setting are often taken to the operating room emergently. The work we have completed, thus far around understanding the use of checklists, team training, and understanding SOV, has been helpful but perhaps not sufficient. The most recent tally indicates that we have much work to do. There have been three studies that have called into question whether we have made any progress at all in reducing patient harm. The first of these recent studies found that the rates of injury due to medical error remained unchanged between 2000 and 2008 at 10 North Carolina hospitals.[24] Additionally, a report from the Inspector General of the Department of Health and Human Services revealed that Medicare patients experienced substantial harm in US hospitals as recently as 2008.[25] Finally, using IHI “Global Trigger Tool” methodology (standardized review of patient charts), it has recently been reported that one in three patients are harmed during their stay in the hospital.[26]

While our slow progress may seem disheartening, we as healthcare providers must embrace the concept of continuous improvement to ensure safe and high-quality care as our fiduciary duty to the public. Additionally, this work also ensures our economic survival as current successes and future improvements in quality are now tied to our reimbursement. Authorized by the Affordable Care Act, the Hospital Value-Based Purchasing program is the beginning of a historic change in how Medicare pays health care providers and facilities. For the first time, hospitals across the country will be paid for inpatient acute care not only based on quantity of services provided but on quality. The holy grail of attaining zero defects is no longer a journey: The race is on.

Fundamental to the sustainability of patient safety programs is the measurement of effectiveness, sharing of results, and accepting the fact that teams have to continuously improve. So, where are we now when we consider patient safety strategies? Tools and training have been implemented across the nation, and the groundwork has been set. Continuously improving our patient safety strategies must become habit and part of the standard of care. Only then will we sustain our successes. It is clear that such approaches can no longer be dismissed as the latest “flavor of the month” in health care. Our patients, the public, government, and payers all expect us to work as a team and do all at our disposal to provide the best of outcomes. We have developed the patient safety strategies that have enabled us to function as a team; it is now our responsibility to embrace and sustain.