Central Line

Episode Number: 131

Episode Title: Inside the Monitor: Patient Safety

Recorded: May 2024

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Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ADAM STRIKER:

Welcome to Central Line. I'm your editor and host, Dr. Adam Striker, joined today by two patient safety experts, Dr. Monica Harbell and Dr. Emily Methangkool. Today's guest co-edited the ASA Monitor's special issue on patient safety. Obviously an incredibly important topic, so I'm excited to hear what they both have to say. Before we jump in, can you both introduce yourselves and tell our listeners a little bit about your current role and where your passion for patient safety comes from?

DR. MONICA HARBELL:

Sure. I'm Monica Harbell. I'm an associate professor of anesthesiology at Mayo Clinic in Phoenix, Arizona. There, I serve as the vice chair of the patient safety committee at the Mayo Clinic, Arizona. And I'm also really proud to serve as the chair of the ASA committee on patient safety and education. I think most of us go into anesthesiology to be, you know, a patient advocate in the operating room. And really, the ultimate patient advocate is someone that gets involved in patient safety work and thinks about what we can do to improve our care, not only for that patient in front of us, but for all patients. I got really into and passionate about patient safety work as a junior faculty, and being part of the ASA committee on patient safety and education really inspired me even more to delve deeper in patient safety work.

DR. EMILY METHANGKOOL:

My name is Emily Methangkool. I'm the chair of the department of anesthesiology at … of UCLA medical center, and an associate professor of clinical anesthesiology at the UCLA David Geffen School of Medicine. I'm the vice chair of the ASA committee on patient safety and education, and a member of the Anesthesia Patient Safety Foundation board of directors.

Since the time I was a resident, I've been very interested in patient safety and safety culture. And as a trainee, I observed many incidents of where cases were reviewed. And the goal was not necessarily improvement or learning, but rather the allocation of blame. So when I became a faculty member, I got even more interested. I became involved in patient safety and quality improvement work, first as an assistant program director in charge of resident education and patient safety, and then as the chair of the quality improvement and patient safety committee within the department. In charge of reviewing adverse events. In that role, I worked to transform the culture of my department to one where each case was viewed as a learning opportunity for improvement and where there was no blame involved when reviewing cases. Uh, subsequently, I became the vice chair of quality and safety, um, and then moved on to my role here as chair of this department here at U. I've learned throughout my years in safety work that it can be very difficult sometimes and very slow sometimes, but ultimately this work allows us to help so many patients, both our current patients and our future patients, which is why we all went into medicine in the first place.

DR. STRIKER:

Thanks for those introductions. Obviously, you're both very passionate about patient safety, which is an incredibly important topic. And so I'm excited to talk to you both about this. Now, we all know anesthesia care is overall remarkably safe. The specialty has been a pioneer in ensuring patients are safe under our care. Why do you think anesthesiologists have been such effective innovators when it comes to patient safety? Dr. Methangkool, why don't you answer this one?

DR. METHANGKOOL:

So, as with anything, I think the answer is complicated. There has been such a long history of anesthesia being unsafe. For example, when we didn't have pulse oximetry, we didn't have end tidal carbon dioxide monitoring, we didn't have automated blood pressure measurements. Back then, we didn't even have systems to ensure that we were not delivering hypoxic mixtures of gases. Anesthesia machines back then were very primitive. In fact, in the 1950s, the estimated mortality attributed solely to anesthesia was approximately 1 in 2200, and that's improved significantly now. Now it's around one death per 50,000 patients. But the reason I think that anesthesiology has been so successful at patient safety is precisely because we've had such a long history of patient safety issues. We've learned throughout the years that we are the fine line between good and bad patient outcomes, and our vigilance makes a tremendous difference. I also think that the diverse nature of what we do plays a role in being able to think outside of the box for patient safety, for example, we work in critical care in the ICU and labor and delivery in the operating room and the cardiac catheterization laboratory and interventional radiology. And because of this, we have learned to be flexible, to be adaptable, to be resilient, all of which is so important for patient safety work.

DR. STRIKER:

I do want to zoom in on this phrase, “patient safety.” It is thrown around constantly by so many people that I do worry that it loses its luster little, and often it's conflated with “quality improvement.” But they're not synonymous. Dr. Harbell, can you explain how they're different and why this matters?

DR. HARBELL:

Yeah, I think they often get kind of smushed together, but they're really two distinct things. So patient safety is really more focused on the prevention and mitigation of patient harm, while quality improvement work is more focused on how do we deliver effective, efficient, timely and patient-centered care. Quality is about doing the right thing at the right time, for the right person and trying to have the best result. And I think that's really different from the kind of outcomes that we're looking for when we're looking at patient safety work versus quality improvement work, because not all QI endeavors are going to be patient safety focused. They may be more focused on efficiency. And similarly, not all patient safety projects are going to improve efficiency. I think in all of our institutions, QI work gets a lot of attention and a lot of resources. But patient safety doesn't always. And so I think it's also important to focus on patient safety endeavors.

DR. STRIKER:

Okay, Dr. Methangkool, speaking of health care more broadly, despite anesthesia safety, nearly 100,000 patients a year die from medical errors. What are the most urgent priorities for patient safety now and then also in the coming years?

DR. METHANGKOOL:

So while anesthesiology as a specialty has made tremendous progress over the past several decades in improving patient safety, we still face a lot of challenges. The Covid pandemic seems to be just a memory for a lot of us now, but we are still facing constant medical and supply shortages that are a consequence of the Covid pandemic. A good example of how this affects patient safety is drug shortages. For example, we don't always have supplies of epinephrine or calcium for the care of critical patients. But it's even more insidious than that because shortages of compounded medications and syringes, for example, have led institutions and departments to revert back to vial, which increases the risk of a preparation error. The lack of available supply of anesthetic medications have led hospital pharmacies to try to obtain whatever supply they can to keep the operating rooms going, and that can lead to having multiple formulations, appearances, and even concentrations of medications that appear in the operating room. And that only adds to the look alike vial problem and the tremendous risk for medication errors. Another huge area of risk for patient safety is health care disparities. For example, Black and Hispanic women are much more likely to receive general anesthesia for cesarean delivery, and they also have higher rates for maternal mortality. And maternal mortality in the United States far outstrips that of many other high-income countries. There's also some new literature out there that there is racial bias in pulse oximetry readings, and there could be suboptimal care that results because of those problems with the pulse oximetry readings. So as anesthesiologists, we have a really significant role to play in both reducing maternal mortality and recognizing health care disparities, and also intervening to make sure that those disparities don't result in patient harm.

DR. STRIKER:

Well, let's talk about clinicians and clinician safety. Why is clinician safety important for patient safety? Dr. Harbell, do you mind connecting the dots for us?

DR. HARBELL:

Yeah. So when we're talking about clinician safety, we're talking about both the physical and the psychological safety of clinicians. And it's it's really important for patient safety. Health care professionals who don't feel safe either physically or psychologically at work, are going to be much less likely to speak up when they see unsafe situations. And they're also really more unlikely to report any medical errors when they occur. Health care systems are often reliant on error reporting to be able to identify areas and system changes that need to occur to try to prevent future errors. Clinicians who experience poor safety at work are also at really high risk for developing health care professional burnout. And unfortunately, individuals that have burnout and fatigue are going to be much more likely to be involved in a medical error. And the more burnout that an individual experiences, the more likely they are going to be to want to leave medicine altogether, which can make staffing shortages and production pressure and physician turnover issues even worse. And that could lead to even more medical errors.

DR. STRIKER:

Well, I do have some more questions for both of you, but we're going to just take a quick break, so please stay with me.

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DR. JEFF GREEN:

Hi, this is Doctor Jeff Green with the ASA patient safety editorial board. The bed to bed transfer that occurs at the start and end of nearly every surgical procedure is an often under-recognized hazard that can cause patient harm. Patient falls and the accidental removal of tubes, lines, or drains can lead to injury. Checklists and protocols are available for optimal lateral transfer and supine to prone transfer, but steps can be omitted in the busy or using a simple, standardized verbal memory tool where questions are posed to the team can help ensure safe patient transfers. For example, on the count of one, the team has asked that lines, drains and tubes are able to move with the patient on the count of two. The team has asked that both beds are locked. Verbalizing safety concerns during transfer helps the entire team work as one to identify issues before they cause problems that threaten patient safety.

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For more patient safety content, visit asahq.org/patientsafety.

DR. STRIKER:

Well, let's talk about the phrase we've all heard many times: zero preventable harm. A, is this achievable? And Bm are we going about aiming for zero harm the right way? Dr. Methangkool?

DR. METHANGKOOL:

So zero harm refers to the goal of no harm coming to any patient, provider or team in the course of providing health care. But at the same time, given that health care is in itself a very high-risk endeavor that's fraught with risk for complications, we also have to acknowledge that some harms are simply inevitable or unpreventable. For example, the side effects that come with chemotherapy treatment. So a better way, I think, to frame this is in terms of zero preventable harm, in that there should be no harm that occurs when an action or intervention could have prevented it from happening in the first place. There are a ton of organizations, for example, the American College of Healthcare Executives, the Institute for Healthcare Improvement, the Lucian Leape Institute, that hold the zero preventable harm as a core value to pursue. And their reasoning is that anything short of zero, as the goal accepts that errors are inevitable and gives permission for errors to happen.

On the other hand, however, we work in systems that, as I mentioned, are very high risk. They're very, incredibly complicated, and they work with humans who interact with systems every step of the way, and they are subject to very normal human fallibility. As such, zero harm may not necessarily be possible given the human factor element, and to pursue such an impossible goal is to set up the goal for failure from the beginning. In addition, many individuals work in systems with insufficient resources to ensure zero preventable harm. So in pursuing zero harm as a stated goal, it could lead to moral injury in those individuals. It could lead to burnout. It could lead to attrition.

So then the question is, what should we do if zero preventable harm should be the goal, but may not necessarily be realistic or achievable? And I think it's important that we recognize that as anesthesiologists, we have the tremendous responsibility to be the foremost patient safety advocates, both inside and outside of the operating room. We should advocate for the resources we need to improve patient care and patient safety. We should constantly work towards eliminating sources of preventable harm and error within our health care system. For example, looking at how we tackle normalization of deviance and workarounds, and what we have to do is hold the ideal of pursuing the most high quality and safe care that we can possibly provide.

DR. STRIKER:

All right. Dr. Harbell, as doctors, we often focus on when things go wrong. What do you think about the value and focusing on on what we do right?

DR. HARBELL:

Yeah, you're right. We spend a lot of time and resources focusing on adverse events, focusing on when things go wrong. And while that is important, these are rare events, thankfully, right. And we end up missing learning from the vast majority of times when things go right. You might have heard about this referred to as safety one versus safety two. Safety one is when efforts to improve safety really just focus on what goes wrong or could go wrong. It's all very reactive or retrospective, right? So changes are going to be made when an adverse event occurs or when something is considered an unacceptable risk. Safety two broadens that mindset a little bit more. It realizes that things do not go well because people simply follow procedures and work as imagined. Things go well because people make sensible adjustments according to the demands of the situation. It recognizes that humans are valuable resources for adding system flexibility and adding to safety. If we ever only look at those adverse events, we can only react to things once they've already gone wrong. Whereas we can often have a much more proactive, prospective approach if we start to look at safety two and all the different ways in human performance and how it interacts with the complexities of health care to make things go right.

DR. STRIKER:

Now, this one I want to ask both of you. Are there things we should all be doing? Do you mind both talking about some safety strategies that have proven to be effective?

DR. METHANGKOOL:

So I think an important strategy to keep in mind is that we really have to create a culture of safety where everyone recognizes the importance of patient safety, where everyone is willing and able to speak up for safety when it's needed. A robust culture of safety promotes psychological safety as well as inclusive leadership behaviors, so inclusive leaders model professionalism and speaking up behaviors, and they also actively solicit the contributions of those who are not usually empowered to speak. And really, everyone can do this even if you don't have a title. We are all leaders in some aspect, whether it's in the operating room or whether we are just the attending in charge of the medical student or the resident for the day. On the part of national organizations, they have to continue to uphold the importance of patient safety and provide training and education on how to implement safety culture, psychological safety, and how really to create realistic interventions for safety.

DR. STRIKER:

Dr. Harbell, anything to add?

DR. HARBELL:

Yeah, I think that's a great summary. Different, you know, concrete things that we can do every day in our OR is to model professionalism and psychological safety. We can speak up for safety when we see things that may put our patient or our coworkers at risk. And that we can try to do everything we can to prioritize safety in every case that we do. I think on an institutional level, on a department level, it's incredibly important that safety is prioritized within that institution and that department. It's incredibly important that safety events and quality measures are discussed at every level, and even and especially at the highest levels of leadership, so that the highest levels of leadership not only know of what the safety issues are, but that they can be accountable for making sure that those safety issues are addressed. I think it's incredibly important that patient safety work receives protected time and resources for staff to actually engage in the work. It's incredibly important that we actually measure our safety culture using the different validated tools, and that we use that data to try to drive further improvements in safety culture. And I think it's also incredibly important that departments and institutions actually have a designated leader for patient safety work, someone that's separate from quality improvement work like a patient safety officer. And I think as anesthesiologists, we are uniquely positioned, given, you know, what Dr. Methangkool said about how we interface with so many different departments within a medical institution, that anesthesiologists are uniquely positioned to serve as patient safety officers, and that leader can help establish and lead multidisciplinary safety committees that can really look to address any safety issues within the institution.

DR. STRIKER:

You touched on communication, which is such a key to patient safety. Dr. Methangkool, can you talk a little bit about why that is so essential, and also specifically how teamwork and team building impact patient care as well as patient handoffs?

DR. METHANGKOOL:

So unfortunately, communication failures are very frequent in the perioperative setting. Um, one study has cited that communication failures occur in up to 30% of all procedural communications as often as every few minutes. And when communication failures happen, they lead to patient harm. Handoffs are a really good example of this. When there is missing information about the patient, there can be things that are overlooked that really lead to significant patient injury. There have been analyses of both surgical and anesthesia malpractice databases that have found that communication failures are quite frequent. They are more likely to be paid out when they are brought to suit.

And one thing I think that's important to remember when we are thinking about how to tackle communication issues, is that we don't work in a silo. Unlike other specialties, we always work within the context of a team. So a surgeon, a proceduralist, a nurse, a technician, an anesthesiologist. And because of that, we have to be able to communicate with each other for effective patient care. We have to be able to work together as a team. There is good evidence that good communication and good teamwork enables good patient outcomes. For example, there was a recent study that found that after Teamstepps was implemented in the O.R. setting, there were decreased patient safety incidents, decreased turnover times, and also improved worst case on time starts. And for those who don't know, Teamstepps is a multidisciplinary training program that teaches good leadership and good communication. There's also another recent study in JAMA that showed that surgeons and anesthesiologists who work together frequently have better patient outcomes after major abdominal oncologic surgery. And team familiarity is important because it engenders better communication, as well as shared mental models that allow the team to be more adaptable and handle unexpected events in a much better way.

DR. STRIKER:

One last question for both of you. We all know that patient safety is so critical to what we all do every day. And because of that, why do you think a special issue on this topic is so important? And what are your hopes for this issue?

DR. HARBELL:

You know, as anesthesiologists, patient safety is at the core of what we do for our patients. And as you know, as we work and interface with so many different teams and departments all around the hospital, that we are really uniquely positioned to be incredibly effective in patient safety work. My hope is that this issue really ignites more excitement and passion for patient safety work. Um, not only for the next generation of anesthesiologists, but also for practicing anesthesiologists, that it brings more attention to the patient safety issues that we're facing and gets people excited to to get their hands on dirty and, and start doing all the hard work to help improve patient safety for all.

DR. METHANGKOOL:

I absolutely agree with everything that Dr. Harbell said. I think it's important to celebrate all of the achievements that anesthesiology as a specialty has made in terms of patient safety, but at the same time, we cannot become complacent because patient safety issues remain. We are still hearing problems with medication errors, wrong site surgery, airway management issues, problems with communication and teamwork, all of which can lead to patient harm. So my hope, at least for this issue, is to highlight these ongoing issues for the readers of the ASA Monitor, as well as for members of the ASA, but also to engender discussion and thought about what each of us can practically do to tackle issues around health care disparities, around technology, around burnout, around all of these patient safety issues. And I really hope that we can use this to inspire the next generation of patient safety researchers and experts who are going to take our specialty even further.

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DR. STRIKER:

Well, this has been a great conversation. I just want to thank you so much for joining us to share your particularly unique expertise and insights. And to our listeners, thank you for joining us on this episode. Thank you also for all the likes, shares, follows reviews. Please tell some colleagues and make sure to tune in again next time.Take care.

VOICE OVER:

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