A recent study shows that medical errors are likely the third leading cause of death in the U.S. The findings by researchers at Johns Hopkins were controversial, but one of the takeaways has been that the health care system should take lessons from aviation.
The airline industry has seen a dramatic increase in safety, including fewer crashes, since adopting a set of standardized safety practices. Eastern Maine Medical Center in Bangor has spent four years integrating aviation-inspired protocols in an effort to improve safety and reduce medical errors.
One of the first places where EMMC applied those aviation protocols is where the stakes are often the highest: the operating room.
“Our first patient is a gentleman who had a fractured dislocation to his elbow about nine months ago,” says orthopedic surgeon Dr. David Carmack, who is going to remove and tighten some of the hardware embedded in the patient’s arm from a previous reconstruction.
It’s a pretty straightforward surgery. Still, there’s room for error.
“Room for error, in orthopedics especially, is laterality. The correct side, left and right,” he says.
Operating on the wrong part of the body, the wrong patient, even doing the wrong procedure is rare in hospitals, but it does happen. To prevent mistakes, EMMC started working with a company four years ago called LifeWings, which takes best practices from the aviation industry and adapts them to health care.
One is a team huddle right before launching into surgery. It’s called a time out.
“Are we all ready for a time out?” a charge nurse calls, and everyone in the OR stops, faces each other, and reviews what they’re about to do.
“So what we’re going to do is a revision of his internal fixation and take some hardware out. I don’t anticipate any critical events or critical blood loss,” Carmack says, taking the lead.
Time outs themselves aren’t new. They became a quality standard in 2004. But subsequent studies have found that time outs really haven’t done much to prevent surgeons from operating on the wrong arm or leg.
Part of the problem, observers say, is that time outs are not standardized. That’s why EMMC sought help from LifeWings.
A checklist posted on the OR wall lists the information that teams review before every surgery — about the procedure and the patient’s allergies and medications — and it ends with a crucial statement by the lead doctor.
“So that completes the time out, and the expectation is that everyone will speak up with safety concerns or suggestions throughout the case,” Carmack says.
That statement is important because it emphasizes the principle that everyone on the team is responsible for the patient’s safety. It may sound like a no-brainer, but EMMC Chief Medical Officer Dr. James Raczek says sometimes top-down health care culture can make it hard for people to speak up.
“It’s not unusual for someone who might be a technician not to feel it’s appropriate or the right environment to ask a question of a nurse or physician because of that difference in status, that difference in hierarchy,” he says.
“Before, the doctors had more — maybe not control is the right word, but influence,” says Steve L’Italien, a surgical technician. “And now we feel we have more of an influence now that they want to have our input, so it’s not so scary to say something.”
After working to empower employees and improve communication in the OR, EMMC started adapting LifeWings protocols in other areas.
In a typical shift, Frank Connolly, a transporter at EMMC, will move between 25 and 35 patients to different areas of the hospital, for X-rays, testing and other procedures.
“Hand offs are one of the biggest times for safety issues to occur because of communication,” he says.
“It can be anything from not knowing the patient can’t stand up, risking a potential fall,” says Andrea Huntley, program manager for LifeWings at EMMC.
So, when Connolly picks up a patient for an echocardiogram, he asks the staff nurse seven questions, which are also printed on a business-size card he keeps in his pocket for quick reference.
Connolly says those standard questions ensure nothing slips through the cracks.
“We’re not giving excellent care to one patient, and then mediocre care to the next,” he says.
Though it’s working well now, Connolly says, LifeWings initially had a turbulent start. It took a few attempts to create an effective communication protocol. And some staffers were slow to get on board.
“I guess I would consider myself somewhat of a resister in the beginning,” Carmack says.
Back in the OR, Carmack says he bought in after he had a near miss that was caught by a new, young surgical tech.
“Learning about near misses and actual problems and complications that really are preventable, I kind of made the decision that there’s no good reason for me not to be 100 percent behind this,” he says.
After EMMC implemented LifeWings safety protocols in the OR in 2013, it recorded 10 surgical errors. The next year it had edged downward to nine, and last year, it had dropped to one.
Carmack says these tools aren’t revolutionary — they’re common sense. What makes them work is they’re part of a set process that everyone follows.
The protocols are always being updated. The next change, he says, will be ensuring that EMMC’s post-operation debrief is incorporated at the end of every surgery.
