Never having a never event

The Institute of Medicine estimates that nationwide, preventable medical errors in hospitals unintentionally kill the equivalent of one jumbo jet crashing each day. While preventable medical errors are the last thing a patient should have to worry about when he or she is admitted to a hospital, it might surprise most people to know how much time hospital administrators and clinicians spend with their colleagues, consultants and medical agencies to work to eliminate all preventable medical mistakes.

I am the Executive Director of Professional Services at Eden Medical Center, one of the Sutter Health hospitals in the San Francisco Bay Area. Our hospital treats approximately 1,000 in-patients per month. I chair our Medical Center’s Patient Safety Committee, which was formed almost a decade ago. I spend many hours each month working with our physicians, managers, nurses and virtually all members of the medical center team impacting our patient’s environment of care to develop and implement best practices for our health care teams so that we never have a "never event"--an error that should never happen in a hospital.


In addition to implementing the mandatory Joint Commission best practices for patient safety, our Committee has worked with the Studer Group, and we are using their evidence-based tools to improve patient outcomes. We also utilize best practice tools and guidelines from other agencies such as the Institute for Healthcare Improvement and Centers for Medicare & Medicaid Services.

We have come up with initiatives to make sure our patients have the best outcomes and the safest care when they come to Eden Medical Center.

Our hospital was also one of only six hospitals in the Bay Area to receive a grant from the Gordon & Betty Moore Foundation to develop best practices for patient safety. So in addition to the Patient Safety Committee, our nurses formed the Partners Advancing Clinical Excellence (PACE) Council to look at how to avoid never events from the nurse's perspective.

Our Quality Improvement Committee is a medical staff committee comprised of leaders and members of the administrative executive team, which oversees quality and patient safety concerns throughout the Medical Center.

At Eden, without the support of our physicians and the dedication of our Patient Safety Committee, our progress to improve safety and eliminate preventable errors would not be possible.

What are the most common never events that can affect patients in the hospital?

* Wrong site surgery
* Pressure ulcers
* Falls causing trauma
* Pulmonary Embolism
* Hospital-borne infections, i.e., MRSA, C-DIFF
* Urinary tract infections
* Ventilator-associated pneumonia
* Poor control of blood sugar levels
* Foreign objects remaining in the body after surgery
* Blood incompatibility
* Medication errors

What are the costs associated with these events?

Beyond the unnecessary suffering endured by the patient and family, there are costs incurred by the hospitals. According to a report that came out this year from CMS, pressure ulcers alone cost U.S. hospitals over $11 billion in 2007. If we calculate each item on the CMS's never-events list, the financial impact is staggering. Moreover, the Federal Government is no longer reimbursing for most hospital-acquired conditions, like the ones on the list above.

What are some of the best practices Eden Medical Center has put in place to reduce errors?

Our ongoing mission is to create a culture of patient safety where clinical staff are working with each other in more effective ways and sharing critical information so patient care is never compromised.

We have found that when we drill down to the root causes of medical errors, 75 percent are related to poor communication. Our Patient Safety Committee has adapted SBAR (Situation, Background, Assessment, Recommendation), a framework originated by the U.S. Navy to help the nuclear submarine employees communicate about catastrophic events. We use the principles of SBAR for members of our care teams to communicate about a patient’s condition, regardless of their role on the team. We view the care team as anyone who interfaces with the patient, from housekeepers and dieticians to nurses, doctors and surgeons.

The Patient Safety Committee now has a focused way to set expectations for what needs to be communicated, and how to do it effectively. We are trying to maintain an environment where nurses are comfortable speaking up to physicians, taking a more proactive role in caring for the patient, as opposed to the old model of simply carrying out a physician's orders. Standardized order sets and protocol helps to reduce variability in care among providers, and thereby reduces the potential for unintended human error. Even housekeepers are empowered to remind physicians when they forget to apply antibacterial gel after leaving a patient’s room!

What does Eden do to avoid mistakes during surgery?

We do a "surgical pause" before, during and after every patient procedure. This eliminates the risk of discrepancy between hand-offs to the different medical teams, ensuring we perform the right procedure on the right patient on the right site.

When a patient enters the pre-op holding area, a holding nurse asks a series of questions beginning with the patient's understanding of the surgical procedure about to be performed. The surgeon marks the site on the patient's body with either his initials or "yes" with an indelible pen. For example, if the patient is having knee replacement surgery the surgeon marks the correct knee.

As the patient is transferred to the OR, verification from the pre-op team is handed off to the surgical team. Just prior to surgery, the OR team engages in an "active" time out to verify all patient identifiers. Each team member gives a verbal confirmation that the correct patient is in the OR for the right procedure; he or she is in the correct position for the procedure; the correct site has been marked; and the correct equipment is being used.

We also pause at the end of the procedure to make sure we haven’t left any foreign objects in the patient. Yes, it can and does happen.

Our PACE Council members train nurses in evidence-based practices right at the bedside, and then employ "rapid tests of change," by soliciting feedback from the nurses to quickly evaluate if an enhanced practice works. For the prevention of ventilator-associated pneumonia, we are making sure the patient receives oral care every four hours, since bacteria harbors in the mouth and can travel down to the lungs. We have reduced VAP from 19 in 2007 down to 1 last year.

The PACE Council leaders are also trained in conflict management; conducting effective meetings; coaching nursing colleagues and support staff, and effectively delegating responsibilities.

What changes have you made to the culture to promote patient safety?

Besides clinical practices we have also made an effort to mobilize the entire hospital around patient safety. For example, each month the Patient Safety Committee sends out ballots to our 1,500 doctors and hospital employees to nominate physicians based on our list of Physician Patient Safety Practices. The doctor with the most votes for that month's topic receives a Patient Safety Award and the achievement is publicized in the Medical Center community.

I wish I could say that we are now error free; that we never have "never events." In reality, there is no hospital in the world that can make that claim. While none of our systems are failsafe in preventing harm, by engaging the entire organization in a culture of safety, we have made significant improvements in patient safety in our organization.

Debora Hendrickson is Executive Director of Professional Services at Eden Medical Center, near San Francisco.