zondag 6 juli 2008

The message you hope never to send ....

Via Google Reader ben ik inmiddels op verschillende gezondheidszorg gerelateerde weblogs geabonneerd. Google Reader zorgt er dan voor dat alle nieuwe berichten, gepubliceerd op de weblogs, in de vorm van een Postbus In voor je worden klaargezet. Een krachtig hulpmiddel om overzicht te houden, zonder elke keer alle weblogs te moeten bezoeken.

Eén persoon volg ik al vele maanden. Dit is Paul Levy. Hij is President en CEO van het Beth Israel Deaconess Medical Center (BIDMC) in Boston. Dit ziekenhuis is geaffilieerd het Harvard Medical School. Zijn weblog is genaamd “Running a Hospital”. Paul schrijft veel over kwaliteit en veiligheid in de zorg en over transparantie. Onderwerpen waar ik bijzonder in ben geïnteresseerd. Vanmorgen bij het doornemen van Google Reader trof ik een nieuwe bijdrage van Paul aan onder de titel “The message you hope never to send”. Dit bericht maakte veel indruk op me. Daarom wil ik Paul’s weblogbijdrage integraal met u delen.

(Begin weblog bericht)

An email sent out on Thursday morning. My commentary follows.

Dear BIDMC Community,

This week at BIDMC, a patient was harmed when something happened that never should happen: A procedure was performed on the wrong body part. With the support of all our Chiefs of service, we are sharing this information with the whole organization because there are lessons here for all of us.

While respecting the confidentiality of both the patient and caregivers, here are the key facts: It was an elective procedure, involving an excellent team of providers. It was a hectic day, as many are. Just beforehand, the physician was distracted by thoughts of how best to approach the case, and the team was busily addressing last-minute details. In the midst of all this, two things happened: First, no one noticed that the wrong side was being prepared for the procedure. Second, the procedure began without performing a "time out," that last-minute check when the whole team confirms "right patient, right procedure, right side." The procedure went ahead. The error was not detected until after the procedure was completed. When it was, our patient safety division was notified immediately, and they in turn took all appropriate steps including investigation, reporting and corrective action. The physician discussed the error with the patient at the first opportunity, and made a full apology. The patient is now recovering at home from the injury, which is not life-threatening.

What a horrifying story. What important lessons. We learned that when teams are busy and distracted, it makes it easier to overlook something. We learned that key safety steps, like the "time out," need to occur every single time, since even one failure can be serious. We learned that serious events rarely relate to the performance of any single person. We learned that we have vulnerabilities that we were not even aware of, and that there are surely others out there.

Actually, we re-learned all these things, because none of these observations are new and all of them apply to the entire work place. We have already made improvements in our process for side/site marking and procedural time outs; what can you do to apply these lessons to your work?

The strength of an organization is measured not by counting the number of successes, but by its response to failure. We have made an institutional commitment to eliminating harm, and that requires sharing information about cases such as this so that we all have a chance to learn from it. We still have more to learn from this case, and changes that need to be made, and so will be providing more information in the future.


Kenneth Sands, MD, MPH
Senior Vice President, Health Care Quality

Paul Levy
President and CEO


Before I start, I want to refer you to an excellent story summarizing the case written by Stephen Smith at the Boston Globe.

So, here are a few things you might want to know. The things that went wrong are summarized above and simply should not have happened. The test for our place is to figure out how to make the right things happen 100% of the time. As we work on that, I'll keep you informed.

While I feel incredibly badly about the event, I feel good about the actions taken by individuals and groups right afterward. Here are a few things that went right. (1) The surgeon immediately notified me and his chief of service when he realized that the error had happened. This permitted our Health Care Quality staff to quickly and efficiently interview everyone who was in the OR, while memories were fresh, so we could piece together all the relevant events. (2) The surgeon and others apologized promptly and openly to the patient and explained the nature of the error. (3) When all of our Chiefs of service met to review the case, they unanimously agreed that the case was serious enough that the email above should be sent to all of the thousands of people working in the hospital.

I could not say with any certainty that all three of these things would have happened even three years ago, when people would have been a lot more protective and skittish about this kind of disclosure. But the focus of our hospital on improving quality and safety and our emphasis on eliminating preventable harm and on transparency of our clinical results has taken hold in a very strong way. This is a cooperative effort of the clinical and administrative and lay leadership -- and it takes all three groups to make it happen.

On this particular case, though, one of our Board members put it exactly right: "Protocols are meant to make procedures insensitive to distraction and busy days. These are inadequate and embarrassing excuses. The 'culture of safety' has not permeated the front lines. Culture of safety training, and application of advances in safety science, I believe, are critical to preventing the type of complex harm that occurs in hospitals. Not just for new staff. For everyone who wears a BIDMC badge, or is affiliated as a physician to the hospital. I know that this is a new science, and a new way of doing business, but this event might just give that leverage needed for change."

While we explore lots of ideas, one already in my mind and that of this Board member would be to make a video with the actual people -- doctors, nurses, surgical techs -- who were in the OR at the time to explain what they saw and felt and what they learned from the experience. While they might be in too much distress to do this right now, they might agree over time, and their doing so would create a powerful message at every orientation, at nurses and departmental meetings, and conferences. Of course, if the patient would agree to participate, that would lend even more power to the story.

As noted by the Board member, "The video could pepper in the stories of near misses and other incidents to keep the lesson broad. The narration would guide the audience to consider challenges and accomplishments -- and work ahead. It could be a 20-minute masterpiece, shown at every orientation, nurses meeting, discussed by chiefs, shared at conferences. Transparency as opportunity, social marketing. It would get people talking, and thinking."

Your thoughts and suggestions?

(Einde weblog bericht)

Ik vind het buitengewoon moedig en grensverleggend dat Paul met dit bericht breed naar buiten getreden is. Ook uit de reacties op zijn bericht (zie weblog van Paul) valt af te leiden dat ook BIDMC-medewerkers onder de indruk zijn en achter deze openheid staan. Ook de moeite van het lezen waard is het krantenbericht in de Boston Globe, dat kennelijk op het interne emailbericht is gebaseerd. Bijzonder ingetogen en feitelijk. Ook de acties die direct na het voorval zijn ondernomen zijn wat mij betreft heel waardevol, ook voor de Nederlandse praktijk. In dat kader schreef ik al eerder over de "Sorry works campaign". Tot slot volgt er maar weer eens uit hoe belangrijk het is dat de te opereren zijde van de patient adequaat wordt gemarkeerd en dat de zogenaamde "time-out procedure" net voor de start van de operatie te allen tijde wordt gehanteerd; ook in stressvolle/hectische omstandigheden. Dan liggen de vergissingen en verwisselingen bij uitstek op de loer ..........

1 opmerking:

Dimitri zei


Al een tijdje lees ik met interesse uw blog, naar aanleiding van dit artikel wilde ik u attenderen op de volgende site waarop geschreven wordt over kwaliteitsverbetering in de zorg en waar de vinger op heel herkenbare zere plekken gelegd wordt. http://cecc.nl/ Erg interessant om te lezen en zeer leerzaam.
met vriendelijke groet Dimitri