Counter Culture

Contrary to what my summers at the Center for Talented Youths may suggest, I was not a gifted science student.  Labs made me especially nervous because they put my knowledge to test amidst combustibles and corrosives.  But all that changed in Professor Paul Baures’ Organic Chemistry II Lab.  He was unflappably patient when we asked questions we should have learned in lecture, and unfailingly kind whenever we drained the wrong layer, knocked solutions over, or broke yet another pipette.  Professor Baures created a culture where instead of diluting solutions with water to ‘look right,’ we felt safe and encouraged to work until we got it right.  I even went on to be an orgo lab assistant*. 

(Goggle Gang, 2007.  One of my favorite pictures.)

I hope you have felt the magic of a Professor Baures.  They demonstrate how much setting the right tone and culture matters.  It’s no surprise that positive work cultures are associated with better outcomes.  In the hospital context, that means fewer adverse events and medication errors.  But does that mean we’re all doomed if we don’t have a Professor Baures in our workplaces and hospitals? 

Not quite.  Professor Baureses are rare, precious things.  But public health has figured out interventions that can be implemented on a systemic level to change workplace culture.  These cultural interventions recognize that it’s often not enough to just have a good solution; solutions need to be accepted by the team using them.  The Comprehensive Unit-based Safety Program (CUSP) at Johns Hopkins is one example.  It involves training staff in the science of safety, a lot of talking about safety, learning from defects, and adding tools for improvement.  All this may sound common sensible and maybe even too touchy-feely for the workplace, but the results are astounding.  At Johns Hopkins hospital, bloodstream infections in many ICUs dropped 90% over 18 months after CUSP implementation.  When the program was replicated across the state of Michigan, it reduced hospital deaths by 10%. 

The effectiveness of this CUSP intervention has a few good lessons for public health.  We don’t always do what we ought to do, and when we mess up, it can be hard to speak up and learn from the mistakes.  Public health once again succeeds by focusing not on the individual, but the bigger picture.  By building a culture of safety, interventions like CUSP change the norm of what we should do; the rules become easier to follow when everyone follows them.  With the system in place, every workplace can feel safe and conducive to effective workers, whether you have a Professor Baures on hand or not.   

*Actual conversation I had as lab TA: “Is aluminum chloride corrosive?” “Well, does it burn?”  “Sort of.”  “Wash your hands more often, James.”

Airplane!

"It’s important not to define safety as the absence of accidents." - Captain "Sully" Sullenberger

(Found this RyanAir infograph
hilarious in 2006; I forget why)

We are still technically on hiatus, but an article in the Times this morning tempted me to write a few quick sentences.  Citing data from the Aviation Safety Network, the article reports that flying in airplanes has literally never been safer.  The US has not had a fatal plane crash in 4 years.  And the risk in death for passengers in the US is now 1 in 45 million.  How do you like them apples?



Medical quality and safety, which I had just begun discussing as a public health problem a few weeks ago, is often compared to aviation safety.  Both professions require a combination of human skill and maneuvering of ever-changing technology.  Protocols and "acts of God" matter for both.  And in both industries, lives are at stake.  Lots of them.  This article is remarkable not only for illustrating what can be done when an industry is committed to reducing accidents and how to do it-- 

After another series of accidents in 1996, federal officials set a goal of cutting accident rates by 80 percent over 10 years. ... Since then, the F.A.A., airlines and pilot groups have stepped up efforts to share safety concerns through a series of voluntary programs. Airlines agreed to participate after obtaining assurances that the information would not be used to discipline them.  -- Jad Mouawad and Christopher Drew for the Times

--but also how much more is to be done.  As Captain Sully's quote above illustrates, this report should be an encouragement for public health rather than a reason for complacency.  Shirley Surely, there are miles to go before we sleep.

Mistakes Matter

(Mistake 2003.)

We all make mistakes.  Some are big but turn out to be inconsequential, like when I applied to the wrong master’s program at Emory University.  Months later, the kind folks in the MPH program called to tell me that they had passed my application along to the MSPH program they thought I was better suited for and that I was accepted to both programs.  Best mistake aftermath ever.  In medicine, sometimes patients are given the wrong medication dose but suffer no ill effects.  Some small mistakes, however, have large, lasting impact (see: offspring, unplanned; see also: Lee, Joy L.).

Like you and me, healthcare workers can mess up on the job.  Some mistakes are preventable, some not.  Some harm patients, many don’t.  But their mistakes become a public health problem when preventable errors are left un-addressed and systematically harm population health. 

My father is having heart surgery next week.  I have literally watched sausage get made, and a live chicken transform into a carcass and then my lunch without losing my appetite.  But I cannot say the same of watching how healthcare is made.  As a health services researcher in training, I am very familiar with the seminal Institute of Medicine report To Err Is Human.  I know that tens of thousands of hospital deaths result from preventable medical errors each year.  That the annual economic costs of these errors amount to $17 to $29 billion.  And how these errors can shake the patients’ trust in their physicians.

The upcoming surgery makes me nervous for all the places where mistakes can happen, but in recognizing errors as a public health problem, we are also able to treat them with public health solutions.  Rather than eyeing each nurse and doctor suspiciously (bad for frown lines), I can look at the structures of the hospital.  How do these providers communicate with one another?  How do they know they're not forgetting anything?  Do they rely on messy handwriting for prescriptions?  The majority of medical errors are not caused by malicious, negligent individuals, but faulty systems.  And in fixing faulty systems, by implementing checklists (surely you have heard of checklists), automating processes, or changing organization cultures, our hospitals and providers can better focus on the important task of keeping you, me, and my dad healthy.  

This light post is the first in a few I plan to write on this public health problem.  In the coming posts, we’ll look at some specific interventions that work to improve patient safety and reduce errors.  Until then, remember to always measure twice and cut once.