Bristol Hospital, a general medical and surgical hospital in Bristol, CT, recently celebrated over a year without a safety error. How did they do it? By implementing a simple but effective method proven successful in other industries.
In 2010, board members of the Connecticut Hospital Association began discussing ways to improve patient safety and eliminate medical errors. Doing so required developing standardized procedures, examining how patients can fall through the cracks, and acknowledging and learning from mistakes. CHA partnered with Healthcare Performance Improvement, a national leader in using “high reliability” science to improve safety. The “high-reliability” strategies are similar to those used in aviation and nuclear power.
As part of the initiative, Connecticut hospitals adopted five safety habits meant to encourage people to anticipate and mitigate problems. They’re referred to as “CHAMP”:
Communicate clearly – Repeat backs with clarifying questions and using phonetic and numeric clarifications. For example, when a nurse or other medical professional is reading aloud the dosage for a patient’s medication saying one, five instead of 15, which can easily be mistaken for 50. Or, phonetic alphabet to avoid having someone mistake “neurology” for “urology.”
Hand off effectively
Attention to detail – One Connecticut hospital reduced the number of surgical-site infections by having doctors use a separate set of sterile equipment to sew up patients, decreasing the risk of contamination.
Mentoring – cross-check and coach teammates, and promote “speak up for safety.” For example, there are times when doctors prescribe medications they know their patients may be allergic to, but they’ve decided that the reward outweighs the risk. If a nurse sees that a patient is scheduled to receive a medication that could cause a reaction, they now question the doctor to make sure it’s what he/she wants and not an oversight.
Practice and accept a questioning attitude – Obtain validation and verification
By 2013, every hospital in the state committed to the “high reliability” program. Part of the program included three hours of training by all employees; the training is now a requirement of all new hires. So far in Connecticut, more than 10,000 people have been trained in high-reliability practices and behaviors through the program.
Additionally, nearly all hospitals in Connecticut hold a daily “safety huddle,” where hospital leaders from each department meet and discuss any and all safety concerns, as well as what happened the day before and any potential concerns in the day ahead. Is an area short-staffed? Is some piece of equipment down?
Bristol Hospital officials said they saw an immediate improvement in serious safety events – anything caused by the hospital because of human error that hurts or kills a patient or lengthens their stay. In 2013 Bristol experienced 25 such events. By 2014, the hospital was down to four, and by 2015 there were only two incidents, both in early January.
Nationwide, there are variations in the extent to which hospitals have focused on reducing errors, but Connecticut is the first, and only, state in the nation to conduct a statewide “high reliability” collaborative. Whatever method is used, the primary drive for change must ultimately come from the health care organizations themselves.
Attorney, certified civil mediator, and award-winning author of the Zachary Blake Betrayal Series—Mark Bello is also the CEO of Lawsuit Financial and the country’s leading expert in providing non-recourse lawsuit funding to plaintiffs involved in pending litigation. He is also a member of the State Bar of Michigan, a sustaining member of the Michigan Association for Justice, and a member of the American Association for Justice.