Stories about these errors, and infections are often heart wrenching. Some clinicians who were so devastated by a mistake have left their practice. Patients talk about these issues and share their stories more than ever. The Walking Gallery uses art to bridge the gap between patients’ experiences and the industry that cares for them. We can learn from every story.
Poetry as a Teacher
I am reminded of a poem from a long ago course in English Literature. Donne’s famous 16th century work, Meditations, provokes an examination of isolation versus interconnectedness which we face even today.
“All mankind is of one author, and is one volume; when one man dies, one chapter is not torn out of the book, but translated into a better language; and every chapter must be so translated…
No man is an island, entire of itself…any man’s death diminishes me, because I am involved in mankind…”
Do we really believe we are all one? If we do not see ourselves as part of the bigger picture, Systems Thinking can never be an effective approach to patient safety. We may be able to follow the processes and make changes but without the belief that we each have a role in the greater whole of patient care then it is very easy to slide into the unconscious blame game. This is a very human behavior, and an extremely difficult mindset to change.
Patient safety is not just an issue for clinicians. Everyone in the hospital is responsible for this fundamental …“First Do No Harm”. That means hospital IT, purchasing, and finance teams are part of this whole called “the environment of care”. If your organization is not thinking this way, then the mindset is still one of isolation. Life in silos does not solve infections and other errors.
When Donne wrote, “when one man dies, one chapter is not torn out of the book, but translated into a better language”, I believe we can see ourselves here. If you work in hospital IT or finance do you know how many infections occurred in your hospital last week, last month? If old Mr. Jones becomes infected because we did not take out his urinary catheter for several days, when it could have been removed in <48 hours and likely avoided the horrendous UTI he is now fighting, do you know? Do you care?
These are uncomfortable questions. Some will even say they are harsh, but the time has come for everyone who takes a paycheck for working in a hospital to understand the enormity of the task at hand, and bring infections and errors near to the zero mark. It is spelled out clearly in the recent review of all the national data on infections. Our adherence to the evidence for preventing Catheter Associated Urinary Tract Infection ranges from 6-27%. Why?
I suggest it is because we are not thinking like Donne’s poem. We do not see the fact that everyone should be focused on best outcomes for patients. It is not just nurses and doctors who create a culture in the hospital. They are the front line of care, but the infrastructure behind them needs to be patient centered as well. If it’s not, nurses and doctors are forced to act like they work on an island, because they are at the bedside and patients are depending on them.
Engaging Patients and Crushing Silos
Safety is personal, a new report from the National Patient Safety Foundation’s Lucian Leape Institute, is a call to action for everyone. Patients, families and all of us working within healthcare who are accountable for safety. It requires partnership to change the culture, and patients are seeking this level of engagement. Why is it not happening? Bluntly stated in the report:
“Too often, standing in the way is the health care system itself…whether by intention or not…because of its fragmentation, paternalistic professional culture, abundance of poor process design, and lack of experience on the part of health care leaders and clinicians with practical methods of engaging patients in safety enterprise.”