Tuesday, September 08, 2015

Lessons from near misses

If our goal is to lead our places to be learning organizations, we must help our folks understand that near misses are gems that should stimulate us to focus on underlying process failure. Why? Well, for every adverse event that is reported in a service or manufacturing organization, there are literally hundreds of near misses.  Each one represents an opportunity to correct a systemic problem that could someday lead to a catastrophic event. Let's look at a recent example from health care.

Bud Shaw published a powerful and deeply disturbing story in the New York Times this past week.  Shaw, a surgeon, was at his daughter's bedside in the hospital when he recognized that she had a serious problem:

I’ve been watching the monitor for hours. Natalie’s asleep now and I’m worried about her pulse. It’s edging above 140 beats per minute again and her blood oxygen saturation is becoming dangerously low. I’m convinced that she’s slipping into shock. She needs more fluids. I ring for the nurse.

I know about stuff like septic shock because for more than 20 years I was a transplant surgeon, and some of our patients got incredibly sick after surgery. So when I’m sitting in an I.C.U. in Omaha terrified that Natalie, my 17-year-old daughter, might die, I know what I’m talking about. I tell the nurse that Natalie needs to get another slug of intravenous fluids, and fast.

The hospital's staff was unresponsive. Shaw broke into the crash cart and administered the saline solution himself. Luckily, things worked out.

After three days in the hospital, Natalie got better. A new chest X-ray showed that there was much less fluid in her chest. Her fever resolved. They changed one of the antibiotics and the nausea she had had all but disappeared. They told her she could go home. They prescribed antibiotics for her to take at home, and removed her IV catheter.

We could say a lot about this incident. The part I'd focus on is what happened after. Shaw doesn't say, but I'm willing to bet that there was minimal or no debriefing of this case by the hospital staff. I say that not because I know the facts: It's just that the pattern of behavior related by Shaw is indicative of a hospital that is well behind when it comes to clinical process improvement.

First, though, let's look at the science, things that are taught in every medical school and nursing school and every residency training program.  Failure to rescue is a major cause of mortality and morbidity in hospitals.  Its causes, though, are multifactorial and the condition often presents itself in subtle ways.  Patient safety expert Robert Wachter has noted:

Analysis of deaths and unexpected cardiopulmonary arrests in hospitals often find signs of patient deterioration that went unnoticed for hours preceding the tragic turn of events. (Understanding Patient Safety, page 283.)

How might the hospital's clinical leadership have helped people learn from this near miss?  The discussion must be set up to "be hard on the problems and soft on the people," making clear that the debriefing is not an investigation targeted at finding fault or assigning blame.  It is an examination of the elements of our work flow that could lead other well intentioned doctors and nurses to similar results in the future.  Let's look at just a few such elements that might be relevant in this case.

What was it that led us to premature closure in Natalie's case?  The symptoms were there to see, yet the doctors and nurses had decided that it wasn't serious. How can we improve our ability to avoid the cognitive error of diagnostic anchoring?

What could our team learn from the fact that a concerned parent could not get the staff to respond? Do we have a protocol in place to activate a rapid response team when key patient indicators warrant? Do we have a patient- or family-activated rapid response program?

Does we use any predictive analytic tools to assess severity of illness that can be tracked over time?

My late colleague Donald Schรถn once described a learning organization as one "capable of bringing about its own transformation."  This is a powerful concept. It suggests that sustained improvement in a place requires--almost as a Zen master might say--that change must come from within.  Near misses provide excellent opportunities for that kind of learning if the leader engenders a sense of responsibility to notice them and act on the information they offer.


nonlocal MD said...

I wonder if the lack of followup on near misses might be due to our overweening rescue complex in medicine - i.e. the near miss was 'rescued', by whomever it might have been, and everyone congratulates themselves on a job well done and moves on. Instead of realizing there shouldn't have been a near miss in the first place and they should be worried as hell.

Marie Bismark @mbismark said...

From Twitter:

Near-misses feel like a blessing - a chance to understand and fix a problem before anyone is harmed.

Jen Morris @JenWords said...

From Twitter:

Some 'patient and family escalation of care' at @NSWHealth http://www.isqua.org/docs/edinburgh-powerpoint-presentations-2013/1235-c12--karen-luxford-kilsyth-wed-reach-patient-and-family-activated-escalation-of-care.pdf?sfvrsn=2

Anonymous said...

I don't understand how this could happen.

In our hospital, anyone, even family members of patients, can call an RRT---which would qualify based on her pulse rate alone. We communicate this to our patients and their support team when they are admitted.

The fact that the nursing staff did not recognize this as an event worthy of an RRT is very troubling.

Paul Levy said...

Sadly, if you work in a place with the rapid response team process you describe, you work in an unusual place. Many hospitals still do not recognize the need.

That being said, I'm willing to bet your hospital did not have such a system in place just a few years ago. So, the interesting question is how did the leadership of your place come to see the light? What was noticed? How did the change occur?

Mark Graban said...

One other angle to consider... why does it take the patient being a loved one for surgeons or others to "wake up" about the problems in hospitals?

Some hospitals talk a good game about "treat every patient as if it were your mother" (or whatever relation you'd want to choose).

The same process and system errors occurred before it was his daughter in the bed... and I bet they still continue?

Carole said...

I respect and agree with nonlocal MD.
Looking forward to the three questions Mr. Levy asked, being answered please.

nonlocal MD said...

Paul, my old shop was a very early adopter of RRT's, probably even before they were widely recognized - I am talking 10 years ago or more. It was in response to the hospital making the front page of the Washington Post for 3 deaths and an ensuing battle between the medical staff and the (previous) administration and Board. I believe it was an attempt to publicly demonstrate the hospital's new sensitivity to safety issues - but how sad that it took 3 deaths, a fired CEO, and a ruined reputation to get it done.

Barry Carol said...

Following the tragic and very sad death of 18 month old Josie King from dehydration at Johns Hopkins in 2001, a rapid response team that parents could activate was put in place. Her mother, Sorrel King, was a strong advocate who helped bring about this change in protocol.

As I understand it, there were early fears among medical professionals that family members would abuse the program by too often calling for the rapid response team when it wasn’t necessary. That turned out to be a wrong and unwarranted assumption. It might be helpful for hospitals that have rapid response teams that families can activate to share their experience about the number of times they’re activated by family members and how many were warranted vs. not warranted.

I find it hard to understand how hospitals can justify not having a rapid response program that families can activate in place. How do they justify or rationalize that decision?

David said...

Along with Jeff Cooper, I still think these should be called “near hits”, but I know it is hard to change the jargon.

As for the case itself, one needs to differentiate whether the problem is inadequate circulating blood volume(e.g., from leaky capillaries as in septic shock), hypovolemia from blood or other external sources of fluid loss, inadequate cardiac output from pump failure(which can also occur in late septic shock), or profound vasodilation form various causes, including septic shock. In other words, a more complete assessment needs to be made quickly, although pumping in volume, as the doctor-father did is a good first rescue step. As usual, it is complicated and normally should not get to this stage, if as was suggested, a quick response by all concerned had occurred.

Roberta Brown said...

From Facebook:

We think the best lessons come from success, but the reality is that they come from failures, and near misses.