June 2003 Bulletin

Advancing patient safety:
Changing the culture in orthopaedics

True progress in patient safety will only be possible if, as a profession, we are able to change the culture of medical practice. In my experience, changing the culture of medical practice from a "shame-and-blame" atmosphere to one that encourages and protects disclosure, and uses information to identify and understand individual and system problems is essential.

Without reliable information about near-misses, defects in the system and adverse events as they occur, only superficial improvements in patient care will be realized. The World Health Organization recognizes that "enhancing the safety of patients includes three complementary actions: preventing adverse events, making them visible and mitigating their effects when they occur." It is also clear that the culture of medical practice must change from one that values and protects physician autonomy to one that values and rewards collaboration and communication as part of a team approach to patient care.

The closer we come to a "team-and-systems" approach, the more we empower other healthcare professionals and patients to participate in preventing problems. Teamwork and better communication are essential to reducing healthcare errors, especially in our current complex system with its rapid patient throughput and multiple caregivers. Such a shift away from a culture of autonomy will also go far to promote the use of accepted standards of practice. Without these changes in culture we can only hope to make superficial improvements in patient safety.

Board workshop

In April, the AAOS Board of Directors participated in a three-day workshop on "Facilitating a Patient Safety Culture in the Orthopaedic Community." (See related article on page 46). The workshop focused on the need to change the culture to eliminate medical errors. It provided an opportunity for the Board–working with the Patient Safety Committee, the Patient Safety Coalition and the AAOS Councils–to begin identifying strategies and programs for influencing change and to develop an action plan for implementing these measures over the next year. We also discussed progress on those initiatives that are already underway. We were joined in our work by several leaders in the field of patient safety who shared with us their insights about the current impediments to change and ways that might be helpful to make real progress in patient safety.

At the outset, it was clear to all that until we move away from "shame and blame," physicians will continue to fear punishment, professional censure and litigation when a medical error occurs, and the error most likely will not be disclosed.

The task is not easy. The review of resident work hours is an example of how resistant the medical community is to change. The original guidelines proposed a limit of 80 hours per week, in-house call no more often than every third night, a minimum 10-hour rest period between duties, and one full free day out of every seven. After much debate, the guidelines were amended, so that the original guidelines are now averaged over a four-week period. Even the maximum continuous in-house duty shift (24 hours) was revised to add up to six additional hours to allow for continuity in the transfer of patient care or clinic obligations. Additional time in the operating room is still being discussed.

One of the workshop speakers, Michael L. Millenson, author of the critically acclaimed book, Demanding Medical Excellence: Doctors and Accountability in the Information Age, shared a personal story. His father was wrongly given a dose of morphine and experienced an allergic reaction. No real harm was done except to the family’s faith in the hospital system. Mr. Millenson shared with the group that "the key to patient safety is to make a commitment to evidence, ethics and effective actions. We need to determine what changes to undertake as individuals and professional societies."

He went on to note that, "The truth is that physicians have responded to medical error with a shrug of the shoulder. It is viewed as the price we pay and the hazard of modern diagnosis and therapy. This fatalistic attitude does not help. Whatever conflict may exist between defensive medicine and professional liability costs, the reality is that very few medical errors end up as the basis for claims in lawsuits.

"Between the health care we currently receive and the care we could have lays not just a gap, but also a chasm. The provision of health care today results in harm too frequently and fails to deliver potential benefits. Trying harder as many doctors and nurses do will not work. We need to change the systems of the provision of care. The reduction in medical errors will need to increase as Baby Boomers age. The errors we prevent may benefit our families, our friends and us. It is essential to adhere consistently to evidence-based standards and to balance clinical autonomy and accountability."

Millenson asked, "Why can’t orthopaedic surgeons set a zero tolerance for wrong-site surgery errors?" He suggested that specialty societies such as ours help individual physicians navigate toward improvement. But evidence and ethics demand that we do something more about patient safety: "Leaders need to blaze the trail for patient safety." The full text of Dr. Millenson’s remarks can be found in Putting backbone into safer surgery efforts.

A second speaker, Michael Leonard, MD, discussed culture and human factors in patient safety. He reported that, "Collaboration and effective communication are very important for culture change. Our error model today is that physicians are trained to be perfect. Knowledge and competence are equated with the absence of error. The medical culture rewards perfection, while error is frowned upon."

He went on to explain that "Errors are inevitable because of human limitations Flawed teamwork is a result of a lack of communication and differing communication styles is a factor in the lack of communication. The overwhelming majority of untold events involved communication failure. Communication breakdowns, which lead to delays in starting surgical procedures, are common. Somebody knows there is a problem but cannot get everyone similarly focused. If the problem is that the clinical environment has evolved beyond the limitations of individual human performance, the answer is to collaboratively monitor one another in order to keep the environment safe."

Lucian Leape, MD, spoke about the need for professionals to be accountable for providing a safe patient care environment. With regard to variation in practice and the system’s tolerance for individual preference, he noted, "Performance standards need to be adopted at local levels. Adherence to these standards should be a condition of appointment to staff and everyone should be monitored. There should be a broad repertoire of methods for remediation. There should be a collaborative effort to take the initiative for the development of a system."

Dr. Leape recommended that, "The AAOS should produce safety tools such as conducting courses in teamwork and human factors and root cause analysis. Task forces should be established to develop performance measures. Move forward in a new way to develop initiatives toward which the membership can work."

What surgeons can do

We will be working over the coming months to incorporate the suggestions of these experts into an action plan that will be shared with the membership. In the meantime, I would like to suggest the following. As practicing surgeons and members of the Academy, there are a number of measures we can incorporate into our own practices that will begin to signal a change in how we do business and begin to allow incremental improvements in patient safety. These include:

Use core safety practices as described by the National Quality Forum and the Agency for Healthcare Research and Quality.

James H. Herndon, MD, MBA

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