Linda Searle Leach M.N. ’80, assistant professor, UCLA School of Nursing and a past president of the American Association of Critical-Care Nurses, still remembers giving a patient at St. Luke’s Hospital in Phoenix, Ariz., two “little orange pills” instead of one, even though the mistake had no medical consequences and occurred more than 25 years ago.
“It was a horrible moment in my life,” Searle Leach recounts, her voice tightening. “The nursing credo is based on protecting the patient, so to violate that with a dosing error was awful. Most people who make a mistake move on, but here I am, 25 years later, still in regret.”
No one can accuse the nurse/educator of not learning her lesson: From stints at USC, Cedars-Sinai and Santa Monica Hospital, to her current efforts at UCLA, which include helping to develop an “early warning scoring system” to assess new mothers’ risks for injurious falls, Searle Leach has spent decades trying to create hospital environments that will prevent mistakes, great or small.
Like patient-safety advocates at UCLA and across the nation, Searle Leach’s efforts received a huge boost 11 years ago with the groundbreaking Institute of Medicine (IOM) report, To Err Is Human: Building a Safer Health System, which concluded that up to 98,000 people die each year in U.S. hospitals due to preventable errors. “Prior to [the IOM report], we never looked at human factors,” Searle Leach says. “The focus was on individual caregivers, rather than on systems, as the major cause of mistakes.”
Walking the floors of Ronald Reagan UCLA Medical Center with the facility’s chief medical officer, J. Thomas Rosenthal, gives life to Searle Leach’s words in an arresting way. As if carefully raising a kite in a shifting breeze, Ronald Reagan UCLA Medical Center’s many patient-safety programs have taken flight through small, incremental measures, which often produce dramatic, even inspiring, results.
“We give about 8 million individual doses of medicine per year in this hospital, and every single one of those doses have about five steps that are tracked on a piece of paper. That’s about 40 million opportunities for human errors.”
J. Thomas Rosenthal
Chief medical officer,
Ronald Reagan UCLA Medical Center
“An acute-care quaternary hospital is a tightly coupled system, where human errors tend to have large consequences,” states Rosenthal, eager to show off a long-in-the-works program for bar-coded medication delivery that has reduced dosing errors in the Seven West unit from one or two per month to zero. “So while we were getting really great at performing miraculous feats of medicine — liver transplants on people who should be dead, stereotactic brain surgeries where the patients leave the hospital after a few days — we somehow lost sight of the simple stuff we all learn in kindergarten, like washing your hands and writing legibly.”
Renee Appleby, nursing manager for the 7th Floor Cardio-Thoracic unit, says shifting to a bar-code scanning system (from visually checking patient wristbands against medications and dosages) was embraced by 90 percent of her staff, virtually overnight. “The patients tell us they feel safer after we explain this process,” Appleby adds, watching one of her clinical nurses, Mat Ilasin, carefully finger keys on a computer workstation.
The bar-code system piloted by Appleby’s team gives nurses access to all the medications and frequencies a physician has prescribed. “This patient has more than 14 active medications,” Ilasin explains, looking at the screen. “I sign on [with a unique ID and password], and the software confirms delivery times and that the meds are what the doctor ordered [from UCLA’s Department of Pharmaceutical Services]. Then I scan the patient’s bar-coded wristband, which has the same medication and dosage information.” Ilasin verifies the data on another computer in the patient’s room and rescans the bar code on the meds to double-check that the dosage and pill, tablet, vial, etc., are consistent. “If at any point in the chain, something doesn’t match,” he nods, “I’m frozen out, and would have to start all over again.”
Prior to the bar-code system, all Ilasin had to ensure accuracy were handwritten slips, which he had to visually cross-check hundreds of times per shift with each medication’s label and each patient’s wristband. Or, as Rosenthal explains: “We give about 8 million individual doses of medicine per year in this hospital, and every single one of those doses has about five steps that are tracked on a piece of paper. That’s about 40 million opportunities for human error.”
Human beings will always make errors, no matter how robust the technology, but that’s not at the heart of how UCLA caregivers set about creating a healthier hospital. The Bruin approach is based on concepts pioneered by a UC colleague, Robert Wachter, professor and chief of the Medical Service at UC San Francisco and a patient-safety expert. Five years after the IOM report, he issued a national patient-safety grade (C+) based on 10 key areas that ranged from accreditation and reporting systems to health information technology. Last year, Wachter issued another grade (B-) that acknowledged progress had been made, in part, due to the maturation of how the health-care field addressed accountability.
“The IOM report was based on how other industries [aviation, nuclear power] were so successful at improving safety outcomes,” Wachter notes. “They found the vast majority of the problems were by well-trained, conscientious employees, operating in dysfunctional environments where the culture did not encourage speaking up; the mistakes kept getting made over and over again by different people.”
Wachter, who also edits the federal government’s two leading patient-safety websites, says shifting to a system where people have confidence there will be no finger-pointing was a big change for the health-care industry, “but one that has largely been responsible for most of the improvements over the last 10 years.”
White-coated neuroscience student Haidang Nguyen is a prime example of the “change without blame” approach. Standing in silent observation outside an ICU room, the intern coordinator is one of 35 volunteers who comprise the Measuring to Achieve Patient Safety (MAPS) Program, a first-ever initiative started voluntarily in 2004 by UCLA’s Department of Patient Affairs in the wake of a visit by the independent (and highly rigorous) health-care accreditation organization called the Joint Commission.
Cait Walsh, accreditation manager, In-Patient Nursing and Interventional Areas and MAPS codirector, says student volunteers like Nguyen are trained to shadow medical-care teams to ensure Joint Commission safety protocols are up to snuff in the areas of administering drugs to patients, drawing blood specimens and hand-washing. Walsh points out that just four years ago, more than 40 percent of UCLA caregivers were noncompliant with handwashing protocols. “Now, with MAPS,” she shares, “it’s 90 percent compliance.”
Preventable, hospital-acquired infections kill thousands of patients in American hospitals every year. So on this day, Nguyen is as rigid and alert as a soldier on recon, scrupulously ticking boxes on his check sheet. Hand hygiene accounts for the majority of MAPS data (Walsh and MAPS co-directors Petra Fritz and Tony Padilla provide their findings to Dr. David Pegues, who oversees UCLA’s efforts to track and prevent infectious diseases throughout its medical facilities). What’s key about Nguyen’s sheet is that it contains no boxes for names — only job designation (M.D., R.N., C.P., R.T., etc.), observation time, patient’s room number, and whether the caregiver washed his or her hands for 15 seconds and/or used an alcohol-based cleanser between each patient contact.
The intern’s goal for his two-hour shift is 30 distinct observations. Copies of the report go to the area unit manager, who will discuss the missed protocols in private with any violators. “She has excellent hand-washing protocols,” Nguyen says quietly of ICU nurse Melissa De Jesus, darting in and out of patient rooms. The compliment is no small thing given the sometimes frenetic and pressured pace of the ICU. Patients are equally appreciative. Medical sales rep Kevin Kosinski ’86 blacked out on the way to a meeting at Ronald Reagan UCLA Medical Center and ended up in the ICU with internal bleeding and respiratory arrest.
Kosinski passed out in the hallway and didn’t want to go to the ER. But a UCLA manager, following “fall” protocol, insisted he go. Kosinski actually fell so hard on his notebook that it ruptured one of his organs, causing internal bleeding and, if not for that UCLA safety protocol, Kosinski says he would have died before ever getting to the ER on his own.
De Jesus “instructed all of my visitors to wash their hands before they come in,” Kosinski smiles, “and makes sure the respiratory therapists all have masks. There are hand sanitizers inside and outside my room … [UCLA] is doing all the little things when it comes to protecting me from infections.”
“The extended timeout we do at UCLA acknowledges that patient-safety outcomes are improved when the surgeon is not the only voice heard in the room, and everyone is free to speak.”
Ronald Reagan UCLA Medical Center
MAPS covers a wide swath, but it’s yet to penetrate the operating room — a pyramid culture that Christine Pizzulli, R.N., manager of OR Services, and administrative nurse Virginia Broughton insist is ripe for change.
“The OR is a place of silos, where individuals focus on what they need to do for the patient, rather than as a holistic team constantly exchanging information,” Pizzulli explains. “The extended timeout we do at UCLA,” Broughton picks up, “acknowledges that patient-safety outcomes are improved when the surgeon is not the only voice heard in the room, and everyone is free to speak.”
The surgical checklist used throughout the University of California system originates from a program called LifeWings that uses aviation safety, leadership, team building and other tools to improve medical safety and quality. The extended format used at UCLA has seven key stopping points, including team introductions by name, patient identity and procedure confirmation, a review of anticipated critical events, confirmation of antibiotic prophylaxis, and an agreement by all team members that issues of concern have been addressed and will continue to be during the procedure. The LifeWings protocol comes directly from the checklists used by pilots, co-pilots and other in-flight employees (rather than operating from memory or experience) for more than seven decades.
“Commercial aviation and other high-risk industries figured out that dampening hierarchies improves safety because the systems are too large and complex for a handful of people to oversee,” Wachter notes. “A workplace where everyone is free to voice their concerns is a safer one, and programs like LifeWings, while not a ‘magic bullet,’ per se, go a long way toward changing how communication is practiced in the OR.”
Broughton and Pizzulli cite two recent examples of the program’s success. “We had a total joint repair where the surgeon had been involved in the design of the ankle implant we had prepped and sterilized before he came in,” Pizzulli recounts. “The manufacturer said the implant had seven pieces, the OR staff confirmed it had seven pieces, [but] during the equipment check off the surgeon suddenly announced it should have nine pieces! So we rescheduled the procedure for another day.”
Neurosurgery cases, adds Broughton, are especially long and complex, “and their OR staffs have been eager to buy in [to the extended timeout, of which each member of the team brings along a hard copy and/or is routed electronically into the OR’s flat-screens]. Anesthesiologists, nurses, surgeons and technicians spend as much as 20 minutes huddled around a patient discussing the nuances of a case.”
That last visual would clearly please Chief Executive Officer of UCLA Hospital Systems and Associate Vice Chancellor Dr. David Feinberg, whose “patients first” management style has been well-publicized. Feinberg says bloodstream infections from central venous catheters (CVCs) were his primary safety concern when he took over at UCLA almost four years ago.
“I basically challenged all the medical facilities in the UC system [starting with the four at UCLA] to decrease the incidence of CVC infections or lose their incentive payouts,” the CEO says. “There was some pushback, with people differing over how infections are reported. But my feeling was simply: UCLA takes care of the sickest of the sick, so how can we possibly allow preventable infections that kill people?”
Nasim Afsar-Manesh agrees. The internist is involved with more than 40 patient safety initiatives at UCLA, including an Internal Medicine-piloted program called the ABCs of Hospitalized Patients. “It’s an eight-point [A–H] evaluative tool developed with physicians and nurses,” she notes. “The C stands for central venous catheters to remind caregivers to be particularly vigilant with hand hygiene and keeping a sterile environment when placing central lines to draw samples or deliver medications.”
And an emphasis on reducing CVC infections has clearly paid off, with rates of bloodstream infections from implantable devices down to less than 1 per 1,000 (at elite facilities like UCLA). Dr. John Stobo, senior vice president, UC Health Sciences and Services, says it’s time for the UC system to start puffing out its chest on the gains made. “By summer’s end, we plan to have a central institute that will focus on what individual campuses are doing, so these patient-safety outcomes can play a leadership role across the U.S.,” Stobo says.
Such praise over safety outcomes is proof that UCLA is working overtime to keep its hospitals healthy, but even its chief medical officer admits there are too many human variables and moving parts to achieve an error-free workplace. The key is constant improvement and vigilance.
“Pilots fly the same flight from New York to L.A. thousands of times,” Rosenthal quips, “just as our surgical teams have done thousands of liver transplants. But here, every time we operate, it’s the first time because each patient is unique.”