Labor and Delivery, Scene 1, Take 1: A woman, who is pregnant for the first time and has had little pre-natal care, arrives at the labor and delivery unit nine months pregnant with premature rupture of her membranes in early labor. She is borderline hypertensive and arrives at the change of shift. The labor nurse is in a hurry to go home and forgets to tell his colleague that the patient is borderline hypertensive and that they need to culture her to ensure she is not infected. The resident on the case starts the patient on a higher than average dose of Pitocin because she does not check a reference to ensure that the dose is correct. The attending physician in charge is not notified because the resident doesn’t want to bother him unnecessarily and appear foolish or incompetent.
The patient develops a pattern of late decelerations on the monitor and the labor nurse casually mentions this to the resident, but when the resident suggests to simply keep monitoring the patient, the labor nurse keeps silent because he doesn’t want to contradict the resident or create any conflict. The patient keeps developing worse decelerations and delivers a baby vaginally with apnea and neurologic damage. The attending physician berates the resident for not calling her and the resident berates the nurse for not being more direct in his communication. The parents of the baby sue the organization, the resident gets peer reviewed, the nurse gets sanctioned and the accreditors are called in to perform a root cause analysis to figure out what led to this sentinel event.
Labor and Delivery, Scene 1, Take 2: A woman, who is pregnant for the first time and has had little pre-natal care, arrives at the labor and delivery unit nine months pregnant with premature rupture of her membranes in early labor. She is borderline hypertensive and arrives at the change of shift. The labor nurse is in a hurry to go home; however, there is a hand-off protocol that requires that he go through an SBAR (situation, background, assessment and recommendation) communication with the incoming labor nurse, and all of the necessary information is transferred. Per protocol, the incoming labor nurse contacts the patient’s primary care clinician who fills him in on additional clinical information about the patient’s medications and her response to managing her borderline hypertension and sickle trait.
Cultures are taken and the patient is fully evaluated per an assessment protocol that must be entered in the electronic system. The resident, per policy, must check the appropriate dose and indications of Pitocin with his iPhone application to ensure that it is both indicated and the dose correct, and an electronic signal is sent to the pharmacy to corroborate the dosing in light of the patient’s other medications. The fetal heart monitor sends an automated alert to the labor nurse, the resident and the attending physician notifying them of the patient’s developing late decelerations. They conduct an urgent huddle to discuss how to first manage the patient’s labor through conservative interventions and then follow by urgent vaginal or cesarean delivery if late decelerations persist or worsen. The entire team comes to agreement, the decelerations persist, and because the fetus is not fully engaged in the birth canal, the attending physician comes in to deliver a healthy infant with a tight nuchal cord wrapped around its neck. A debrief is conducted in which the attending physician thanks the resident and labor nurse for their proactive management and asks if they recommend anything be done differently next time.
These two scenarios play themselves out in hospitals around the world every day. The difference is obvious: The second scenario involves a carefully crafted and executed culture of safety and the first does not, with dramatically different results. A culture is not a policy or even a strategy, it is a commitment that “permeates all levels of an organization from frontline personnel to executive management,” as Dr. Robert Wachter writes in his book, “Understanding Patient Safety.” It involves the assumption that:
- High-risk, error-prone activities will occur and must be anticipated and addressed proactively
- Human beings are not capable of error-free performance and require pragmatic collaborative tools/approaches to enhance performance
- Only in a blame-free environment where everyone is encouraged to identify weaknesses and potential problems without fear of retribution or punishment can vulnerabilities be detected and addressed
- Everyone must work together (and not in silos) with the full commitment of executives and front-line staff to mitigate error and reduce harm
Unfortunately, there are many traditional cultural barriers to prevent this from occurring, including the assumption that:
- No news is good news
- Only bad organizations with bad people make bad mistakes
- Bad events should be covered up and not disclosed
- Accountability should be shifted to the lowest ranking individual involved
Thus, the problem goes on. It takes a strong leadership team backed by a strong board with the full commitment of the medical and nursing staff to turn this traditional culture around so that potential harm can be mitigated and patients can receive safer care. This is often a painful acknowledgment that the way we did things in the past doesn’t work, and the way we need to do things has little in common with the familiar world we came up through. Building a new culture isn’t easy and requires a lot of humility; however, not moving from "take 1" to ‘"take 2" is no longer an option, and our patients deserve nothing less.
Culture is everything--and in Dr. Paul Batalden’s immortalwords, “every system is perfectly designed to get the results it gets.”
Jonathan H. Burroughs, M.D., is president and CEO of The Burroughs Healthcare Consulting Network. He's also a certified physician executive and a fellow of the American College of Physician Executives and the American College of Healthcare Executives.