Reliability in Healthcare
The 1999 Institute of Medicine publication of "To Err is Human: Building a Safer Health System" drew national attention to the issue of patient safety, however insufficient progress has been made to reduce errors.1 Errors in the operating room (OR), in particular, can have severe consequences for those involved, including patients, friends and families, members of the hospital, the hospital as a whole, and even the community.
Statistics on Healthcare
The World Health Organization (WHO) states that 7 million patients have post-operative complications annually while 1 million patients die during or after an operation every year.
Medical errors, such as sponges left in cavities, are the eighth leading cause of death in the United States with an average cost of $5 million per hospital.2
At least 50% of these harmful events related to surgery are preventable; the most common types of preventable errors are technical errors, errors in diagnosis, failures of prevention, errors in drug dosage, and communication breakdowns.2,3
The Joint Commission on Accreditation of Healthcare Organizations found that nearly 70% of sentinel events reported during 2005 were contributed to poor communication. (Greenberg et al 2006, 533; Makary 2006, 746) Furthermore, approximately 75% of the patients died. 5
Changes in on Healthcare
Many healthcare organizations are making changes to increase successful operations in order to become acknowledged as a high reliability organization.6 Research in healthcare has made progress as now "most medical error and patient safety problems are thought to be the result of organizational system factors and deficiencies rather than failures of an individual person." 2 However, many health care organizations still lack a method to evaluate the patient care they are providing. HROs are beginning to provide insight into the context of care that influences reliability.7 It's no secret that the human contribution to adverse events in medicine is significant. However, human contribution is significant in aviation, as well, which has obtained high reliability.8 Until the medical industry understands how HROs principles can be translated for medical professionals, they will continue to struggle to improve patient safety.8
Improving Healthcare through HRO Research
The improvement of patient safety and higher reliability relies on team performance. Examination of highly reliable teams is minimal overall, especially within healthcare.9 It known, however, that the establishment of high reliability teams can aid the organization become highly reliable as a whole. One study presents a structure for promoting safety through three levels-organization, team, and development strategies. At the organization level are the Weick and Sutcliffe principles, as discussed above. The team level consists of guidelines related to each HRO process followed by developmental training strategies.9 The training strategies are perceptual contrast, team coordination, team self-correction, scenario based, guided error, and cross training.9
Another study approached healthcare improvements from an organizational aspect defining four organizational stages of high reliability design, including local, control, open, and deep.6 The researchers stated that "organizational design-including formal structures, procedures, incentives, and informal culture and communication-is crucial to developing and sustaining high reliability healthcare organizations." 6
Relationships between Weick and Sutcliffe's HRO principles and behaviors of care providers have been established, and a few examples of events in the healthcare field in relation to the HRO processes are available in the literature.9 These behaviors and examples in relation to the HRO principles are presented in the table below.
A theoretical framework, based on HRO and NAT theories, is suggested as a way to improve medical errors and patient safety. The study recommends a "big picture" approach instead of organizational interventions (e.g., requiring medication order read backs in single organizational units). Managers should develop a multiyear program to instill changes throughout the organization.2 Another framework, also based on HRO concepts, improves reliability in healthcare organizations. It was applied in over 100 ICUs in Michigan to reduce catheter-related blood stream infections with great success.7
Reliability in Surgery
Many studies have focused on reliability in surgery. The operating room (OR) environment often has diverse medical backgrounds with unclear team relations, and stressful events. This makes for a challenging situation in which communication can fail.10 Four types of communication breakdowns-occasion, content, purpose, and audience-occur in a surgery. The breakdowns occur in about 30% of communications and approximately a third resulted in events that declined patient safety. Examples of communication breakdowns include an increase in cognitive load, increase in tension in the OR, and an interruption to routine.11 The breakdowns are often verbal with one transmitter and one receiver and evenly distributed between pre-op, intra-op, and post-op. Often the information is never transmitted or it is communicated but is inaccurately received, with the most common transmitters and receivers being surgeons. (Greenberg et al 2006, 536) Ambiguity about responsibilities, status asymmetry (one has substantial more power or greater rank), hand-offs, and transfers are common causes of communication breakdowns.3
In addition to communication, teamwork is an essential part of successful surgeries. The Safety Attitudes Questionnaire (based on previous questionnaires which were adapted from the Cockpit Management Attitudes Questionnaire) was designed to "measure teamwork, identify disconnects between or within disciplines, and evaluate interventions aims at improving patient safety."4 If the team members know the procedure, know each team members' role, have the necessary skills and resources, and "have communicative processes that support and encourage behaviors that allow for mutual adjustments to unexpected events or surgical challenges" surgery is more likely to be successful than if they do not.12 Furthermore, "tacit knowledge, team composition, communication, and trust are integral to successful team performance."13 Tacit knowledge, which is often based off experience, is knowledge that is acquired without intention or even awareness. Team tacit knowledge is a vital part of teamwork in a healthcare setting.13
1. Kohn, L. Corrigan, J.M., and Donaldson, M.S. (1999) To Err is Human: Building a Safer Health Care System. Washington, D.C: National Academy Press.
2. Olden, P.C. and W.C. McCaughrin. 2007. Designing Healthcare Organizations to Reduce Medical Errors and Enhance Patient Safety. Hospital Topics. 85(4):4-9.
3. Greenberg, C.C., S.E. Regenbogen, D.M. Studdert, S.R. Lipsitz, S.O. Rogers, M.J. Zinner, and A.A. Gawande. 2007. Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients. Journal of American College of Surgeons. 204(4): 533-540.
4. Makary, M.A., J.B. Sexton, J.A. Freischlag, C.G. Holzmueller, E.A. Millman, L. Rowen, and P.J. Provonost. 2006. Operating Room Teamwork among Physicians and Nurses: Teamwork in the Eye of the Beholder. Journal of American College of Surgeons. 202(5): 746-752.
5. Leonard, M., S. Graham, and D. Bonocum. 2004. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 13(Suppl 1): i85-i90.
6. Carroll, J.S. and J.W. Rudolph. 2006. Design of high reliability organizations in healthcare. Qual Saf Health Care. 15(Suppl I): i4-i9.
7. Provonost, P.J., S.M. Berenholtz, C.A. Goeschel, D.M. Needham, J.B. Sexton, D.A. Thompson, L.H. Lubomski, J.A. Marsteller, M.A. Makary, and E. Hunt. 2006. Creating High Reliability in Health Care. HSR: Health Services Research. 41:4 Part II.
8. Shapiro, M.J. and G.D. Jay. 2003. High reliability organizational change for hospitals: translating tenets for medical professionals. Qual Saf Health Care. 12: 237-238.
9. Wilson, K.A., C.S. Burke, H.A. Priest, and E Salas. 2005. Promoting health care safety through training high reliability teams. Qual Saf Health Care. 14: 303-309.
10. Lingard, Lorelei, Richard Reznick, Sherry Espin, Glenn Regehr, and Isabella DeVito. 2002. Team Communications in the Operating Room: Talk Patterns, Sites of Tension, and Implications for Novices. Academic Medicine. 77(3): 232-237.
11. Lingard, L., S. Espin, S. Whyte, G. Regehr, G.R. Baker, R. Reznick, J. Bohnen, B. Orser, and D. Doran. 2004 Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 13: 330-334.
12. Leach, Linda Searle, Robert C. Myrtle, Fred A. Weaver, and Sriram Dasu. 2009. Assessing the performance of surgical teams. Health Care Manage Rev. 34(1): 29-41.
13. Friedman, Leonard H. and Stephanie L. Bernell. 2006. "The Importance of Team Level Tacit Knowledge and Related Characteristics of High-Performing Health Care Teams." Health Care Manage Rev. 31(3): 223-230.
14. Weick, Karl and Katherine Sutcliffe. 2007. Managing the Unexpected: Resilient Performance in the Age of Uncertainty. 2nd ed. San Francisco:John Wiley &Sons, Inc.