The Science of Safety in Healthcare
Cheryl Dennison Himmelfarb and Peter J. Pronovost
This course will introduce the basic principles of the science of safety in healthcare. Course content will be of relevance to members of the healthcare delivery team, including nurses, as well as the healthcare consumers in the general public.
Workload: 2-5 hours/week
A car’s brakes screech and as a pedestrian your muscles automatically react. But how does the brain figure out how close the danger is or whether to freeze or run? How does the auditory system in the brain transmit information that leads to decisions and actions?
Researchers in Cold Spring Harbor, NY trained rats to listen for sounds and act based on those sounds. According to Zador what we know is sound comes in the ear and what comes out is some kind of decision or action.
“These experiments in rats have implications for how neural circuits make decisions, according to Zador. Even though many neurons in auditory cortex are “tuned” to low or high frequencies, most do not transmit their information directly to the striatum. Rather, their information is transmitted by a much smaller number of neurons in their vicinity, which convey their “votes” directly to the striatum.
This is like the difference between a direct democracy and a representative democracy, of the type we have in the United States,” Zador explains. “In a direct democracy model of how the auditory cortex conveys information to the rest of the brain, every neuron activated by a low- or high-pitched sound would have a ‘vote.’ Since there is noise in every perception, some minority of neurons will indicate ‘low’ when the sound is in fact ‘high,’ and vice-versa. In the direct democracy model, the information sent to the striatum for further action would be the equivalent of a simple sum of all these votes.
In contrast – and this is what we found to be the case – the neurons registering ‘high’ and ‘low’ are represented by a specialized subset of neurons in their local area, which we might liken to members of Congress or the Electoral College: these in turn transmit the votes of the larger population to the place — in this case the auditory striatum — in which decisions are made and actions are taken.”
http://www.nature.com/nature/journal/vaop/ncurrent/full/nature12077.html
Research related to how we act in response to sound cues could help us figure out how to best utilize clinical alarms in healthcare. What factors are involved? should clinical staff have regular hearing tests?
Should the hearing test be geared to the frequencies of sound from the area in which staff perform? Could we test the muscle response to various alarms to determine the psychological and physiological components of alarm fatigue?
PAtient Safety interventions should be guided by the amalgamation of reseach in neuroscience, psychology, engineering, medicine and nursing.
As I new feature I decided to add the category BEST.ARTICLE.EVER. to posts where I utilize information that I feel is from a patient-safety game-changing article. If you look at the word cloud at the bottom of this blog and click on BEST.ARTICLE.EVER. you will get a list of posts containing this designation. If you only have time to read select articles, these are the ones I would recommend.
the first ever BEST.ARTICLE.EVER. designation goes to :
http://www.longwoods.com/content/22845
Cafazzo & St-Cyr (2012). This article and its incredible graphic “The Hierachy of Intervention EFfectiveness” are truly game changers. READ this ASAP. Then read it again and again and again especially when you are trying to address a patient safety issue.
Another article about a recent wrong side surgery: http://www.stltoday.com/business/local/ssm-health-care-apologizes-for-brain-surgery-error/article_05e1c0fa-fd7c-5aa0-a30f-1784edfd7d39.html
“SSM Health Care acknowledged Tuesday that its neurosurgeon and medical staff recently operated on the wrong side of a St. Louis-area woman’s brain and skull.
The admission — and a lengthy public apology — followed a Post-Dispatch story in Tuesday’s paper about a lawsuit filed Friday on behalf of Regina Turner of St. Ann.
“SSM Health Care and SSM St. Clare Health Center sincerely apologize for the wrong-site surgery in our operating room,” Chris Howard, president and chief executive of SSM Health Care-St. Louis, said in a written statement. As a result of the mistaken surgery on April 4, Turner, 53, now needs 24-hour nursing care for her basic needs and cannot speak intelligibly, said Alvin Wolff Jr., her Clayton-based attorney.
According to the lawsuit filed in circuit court in Clayton, the former paralegal “will also continue to suffer from emotional distress, anxiety, disfigurement and depression.”
“This was a breakdown in our procedures, and it absolutely should not have happened,” Howard wrote in his statement. “We apologized to the patient and continue to work with the patient and family to resolve this issue with fairness and compassion. We immediately began an investigation.”
Time outs and checklists have reduced the incident of wrong side surgery but not eliminated the problem. Let’s analyze this from the human factors/risk management Hierarchy of Intervention Effectiveness (see graphic below). 
While checklists and standard time-outs are better than education, they do not reach the level of automation or force function.
In the words of Cafazzo & St-Cyr (2012,http://www.longwoods.com/content/22845)
“Although checklist use has recently made headlines in its ability to reduce adverse events in settings such as the operating room and intensive care (Haynes et al. 2009; Pronovost 2006), it remains unclear that an intervention so fundamentally reliant on human behaviour will be sustainable in the long term without constant enforcement (Bosk et al. 2009). Are all healthcare organizations able to create a culture for the sustained use of checklists? If this solution applies only to organizations that have the leadership and resources to maintain such a culture, checklists – and other solutions reliant on human behaviour – cannot be considered a systemic solution. Given how rare serious adverse events are to the total volume of healthcare encounters, a solution that applies to only a fraction of organizations cannot address this safety issue fully.”
My thoughts: why can’t we ace wrap the WRONG side…with a distinctive sterile wrap designed like yellow police tape (DO NOT CROSS!).. it can be removed once the first cut is made into the appropriate surgical site.
Simple, but it would provide some force function as the team would literally have to remove a wrapping that said “WRONG SIDE” in order to make a mistake!
Graphic: Cafazzo and St-Cyr, 2012
http://www.longwoods.com/content/22845
A safetydog: BEST.ARTICLE.EVER.
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