June 21, 2018
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Getting radical in patient care safety, part 1

Erik Steele
By Dr. Erik Steele

In the good old days of my medical training, when I made a mistake I was publicly flayed by my physician superiors, excoriated by guilt at the harm I had caused a patient, and then vowed never to make that mistake again. So did my nursing and physician colleagues. And it worked; chances were I would never make that mistake again. Unfortunately, I would make many others instead, because a million caregivers riddled with guilt is still a patient safety system riddled with holes.

New ways of thinking about error prevention, however, stand a real chance of making patients safer. Ensuring that these new insights are applied in their care requires patients to take on an even larger role in overseeing the safety of their care, a role that goes beyond patients being the checklist driven safety co-pilot of which I have written previously (see The Patient Safety Checklist Parts I and II that ran in the BDN July 14 and 28, 2011).

These new approaches in error prevention involve new understandings of how the human brain works in complex task performance, and of how the medical world power structure — with its physician commander at the top — may actually contribute to errors in patient care. Application of these new insights will require big cultural changes in health care, changes that patients should look for where they get health care, and should insist on when getting their care.

The first of these has to do with greater caregiver focus on the task at hand, especially in the performance of routine patient care tasks that the caregiver has done so many times they could do it in their sleep. The need for focus in patient care sounds obvious, but usual focus and focus at the level necessary to prevent errors are two different things. This enhanced focus actually requires the caregiver to move some of their thinking about the task from parts of the brain that are more error prone to parts of brain that are less error-prone.

When a nurse caring for you has this kind of focus, you can see it. She or he looks for, and picks up on, your nonverbal communication, and is ordered in the specific sequence of steps necessary for accurate completion of key, but repetitive tasks such as medication administration (where millions of errors in patient care occur annually). Truly focused nurses are seeking not only to answer your questions, but make sure you understand those answers. They are meticulous performing tasks such as identify verification, wound infection prevention and procedure preparation, and perform the same sequence of steps before doing each.

When a physician caring for you does not have this kind of focus you can see that, too. He or she may not make eye contact, meaning they are not looking for your nonverbal messages and information. Their body language may suggest they are trying to leave, to focus on some other task. Their questions are often only one level deep, and they skip past answers of yours that do not fit. They interrupt.

We used to think such caregivers just did not care about us. We now know the problem may not be that they leave us feeling cold, but more importantly, that they may make, or fail to prevent, more errors in our care.

The patient has a role in making sure caregivers treat them with this enhanced level of focus, by asking caregivers who seem distracted or uninterested in their care task to pause and focus on what they are doing for that patient at that time. Ask the caregiver, “Do you need a moment to collect yourself before you do that?” or “You seem distracted — are you OK?” If necessary, ask them to stop what they are doing and regroup, or get someone else to help.

That may be difficult for some patients to do, in part because of something else we are coming to understand leads to a lot of errors in medicine; the power ratio between two people in a patient care interaction. But that’s for the next column. In the meantime, start looking for laser focus on you when you are the patient. Anything less could be not just a little demeaning, but a little deadly, too.

Erik Steele is the former chief medical officer of Eastern Maine Healthcare Systems. He recently accepted a new job at Summa Health System in Akron, Ohio.

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