 2003 AJN Table of Contents
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Issues Update
American Journal of Nursing -
December, 2003 - Volume 103, Issue 12
It Takes a Team to Prevent Errors
Experts call for a team approach to safety.
The operation went well, and Tawnya Brown was recovering. But within hours, Brown, 31, was dead, leaving a husband and an eight-year-old daughter. Brown died on July 24, 2003, due to a preventable human error in a hospital known for its excellence. Through a tragic error for which the hospital has taken full responsibility, Brown received two pints of the wrong blood type during surgery and six more in the recovery room, reported the September 8 issue of the Washington Post. This case is a recent example of how better communication at a hospital could have saved a life.
Health care is not the only profession susceptible to human errors that potentially result in deaths. But as a nonstop “mega industry” where consumer safety is a benchmark for success, hospitals have yet to learn what other big industries have. These industries have applied comprehensive staff-communication programs that some experts believe prevent tragedies.
“I think the public would be alarmed to learn just how many close calls there really are in today’s hospitals,” says Cheryl Johnson, RN, president of the United American Nurses, AFL–CIO, an associate organizational member of the ANA, and a 30-year critical care nurse in Michigan.
Medical errors don’t appear on the National Center for Health Statistics’ list of the top 10 causes of death. If they did, they would rank number five—ahead of accidents, diabetes, and Alzheimer disease—and well ahead of more familiar causes of death such as AIDS, breast cancer, and gunshot wounds, none of which rank in the top 10. In fact, a 1999 Institute of Medicine (IOM) report estimated that medical errors may kill as many as 98,000 Americans each year. To give some perspective, airlines would have to lose about 900 jets in accidents each year to reach the equivalent to this IOM estimate of losses due to medical errors.
The airline industry is one that has taken the initiative to meet the challenge of preventing potentially fatal human errors. Prior to the 1980s, the welfare of passengers and the plane was squarely in the hands of the captain, with minimal substantive input from cabin staff such as flight attendants, says John O’Brien, director of engineering and air safety for the Air Line Pilots Association. But cases such as the TWA flight that crashed in Virginia in 1974 following confusion among flight deck officers prompted a comprehensive review of airlines’ communications policies.
Since then, airlines have taken significant steps to promote better communication among cabin and flight crew, with strong involvement by airline unions.
Programs such as crew resource management (CRM) training, now widely used by airlines, are “predicated on the fact that human beings make errors,” says Bob Francis, former vice chair of the National Transportation Safety Board. “If there is better communication among crew members, the captain and flight deck officers, it’s more likely that you will catch an error that someone else has made or that you’ve made yourself.”
CRM programs were created by airlines about 15 years ago to teach the flight crew how to draw upon the different capabilities and knowledge of a given crew. The Federal Aviation Administration began requiring CRM training for flight and cabin crews in the late 1990s. Assertiveness training is emphasized for cabin and flight deck crews, and captains—while they are still ultimately responsible for a flight—are taught how to utilize the skills and resources available to them through their crews. Other skills include situation awareness, adaptability, leadership, and decision making.
As is often the case with nurses and the health care profession, aviation also has suffered from gender biases that made flight attendants—still 80% female, according to Candace Kolander, coordinator for air safety, health, and security for the Association of Flight Attendants union—defer to the judgment of predominantly male pilots and first officers. Women who have traditionally occupied the subordinate positions of flight attendants (or nurses) were expected to support the pilots (or doctors), and not offer their own analysis.
But now, through role playing and self-critique that are part of the CRM model, the crew is urged to inform the captain of any problems before, during, or after the flight, and the captain is expected to listen. “In an emergency situation, you need input from everyone,” Kolander says. “You need to be able to speak up.”
“There’s no question,” says Francis, that such models have improved aviation safety.
Flight attendants give the CRM communications program a resounding endorsement. Kolander says, “Any person you ask will tell you that you need to have CRM training.”
Such communications models sound starkly similar to the recommendations many nurses make to improve the deplorable level of medical errors.
In particular, improving the exchange of information between doctors and the nurses who serve as the patient’s primary caregiver at the bedside would safeguard against preventable errors. The common-sense act of requiring doctors on morning rounds to get a face-to-face briefing on a patient’s conditions from the nurse at the bedside would go a long way in meeting that goal, Johnson says.
“There are doctors who view themselves as team players and who will seek out nurses’ input, but they are the exception, not the rule,” Johnson adds. “In my experience, hospitals rarely play a role in encouraging doctors to consult with the nurse on duty, in addition to reading the patient’s chart. And there are some facilities where an RN’s input is so poorly received that she wouldn’t think of volunteering it. I think hospitals where RNs are unionized tend to be more receptive to input from their nurses.”
Indeed, the current climate in many hospitals doesn’t appear to foster a team approach to patient care. This was evident last year when the UAN launched a campaign to encourage RNs to get involved in their hospitals’ implementation of the Joint Commission on Accreditation of Healthcare Organizations’ new accreditation standards on staffing. Hospitals chose from a list of 21 new staffing indicators. Nurses overwhelmingly reported that RNs had little or no input into the staffing indicators selected. (To read nurses’ comments, go to www.UANNurse.org/yourturn_archive.htm.)
To get to the root of communications problems in hospitals, the environment must change. “We need to establish a culture which does not blame,” says Pat Holloman, RN, an OR nurse for 50 years at Mount Sinai Medical Center in New York City and a member of the ANA’s board of directors. “We must recognize that our workplace is staffed by people and make allowances for error. Then you establish an environment for handling those errors.”
Likewise, hospitals must take responsibility for developing a clear and consistently enforced system to prevent and address errors, including a forum for employee input: “There has to be a commitment from institutions to foster communication among all involved,” Holloman adds.
The IOM also has advocated, in its 2003 recommendations for reform of health professions education, a more team-based approach to health care, noting that “all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.”
“The problem in both medical and airline cultures is that you have had a hierarchical approach to doing business,” Francis says. “That is not particularly healthy in operations like aviation.”
Creating a system that ensures RNs and other health care professionals are valued and their knowledge and judgment are utilized is necessary in an industry put in charge of caring for the public. For hospitals and the health care profession, it’s time to learn from other industries in which research and role models exist. What are we waiting for?
Susan Bianchi-Sand is the national executive director of the United American Nurses, AFL–CIO, an associate organizational member of the ANA, and was a United Airlines flight attendant for 30 years. She also served as president of the Association of Flight Attendants union and helped transform the image of flight attendants to safety professionals.
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