Teamwork, New Thinking and Skepticism May Help Reduce Hospital Errors

Study looks into what goes right in a complex and busy PICU rarely suffering from adverse drug events

Over the last decade, Nationwide Children’s Hospital has driven down adverse drug events (ADEs) by nearly 80 percent. Although the pediatric intensive care unit (PICU) administers the largest volume of drugs in the hospital to patients with high acuity, the PICU tends to have the lowest ADE rate. 

But progress plateaued across the institution as investigators who work on medication error reduction focused on correcting mistakes retrospectively – an approach called Safety I. They are now often correcting one-of-a-kind medication errors that fail to reduce the ADE rate.

In an effort to move toward the hospital’s “Zero Hero” goal of zero preventable harm, the researchers — physicians, a pharmacist and a psychologist —  borrowed from aviation and nuclear power industries and studied what went right in high-performing units such as the PICU.  

 This proactive approach to safety, called Safety II, recognizes systems are complex and circumstances unpredictable, requiring flexibility and resilience among individuals and the system as a whole in order to avoid errors.

 The researchers believe their study, published in Pediatrics, is the first to identify Safety II behaviors in health care.

 “We’ve made tremendous progress in safety but we felt that to take the last step to zero, we have to do something different,” says Thomas Bartman, MD, PhD, a neonatologist and senior author of the study.

 “We’ve found it’s important to use Safety I and Safety II concepts to drive harm down even further,” says Jenna Merandi, PharmD, MS, CPPS, a medication safety officer and lead author. But, she says, little effort so far has been given to learning what is going right and how that’s being applied.

 Through focus-group interviews with PICU members, Dr. Merandi, Dr. Bartman and colleagues found a number of factors traditionally associated with Safety I that appear to contribute to error prevention. These include individual characteristics, such as experience and an ability to remain calm and focus under pressure; developing and maintaining relationships and open communication and interactions; and structural and environmental characteristics, such as a busy but not overwhelming workload.

However, they also found that individuals in the PICU adapt these behaviors to anticipate errors and manage the unexpected. Furthermore, they developed safe and effective ways to innovate, which is the hallmark of Safety II.

Among the approaches, the unit relied on teamwork to troubleshoot and problem solve when faced with unexpected challenges. “There were discussions with multiple colleagues about a change they were considering before going off protocol,” says Dr. Bartman, who is associate medical director for Quality at Nationwide Children’s.

Team members who came from other units were vital to providing new thinking, the researchers found. But, healthy skepticism to moving away from standard procedures provided guardrails when deviating from prescribed protocols.

“This approach allows people to think critically, create and innovate,” Dr. Merandi says.

Dr. Bartman adds, “The goal is not simply reducing variation in care but to reduce unintended variation and to vary when there is good reason.”

The researchers suggest that applying Safety II makes sense only where unwanted variation in care is well controlled.

Drs. Merandi and Bartman are now planning how and where to test whether Safety II concepts and their specific findings about decisions to vary care in the PICU can be transferred to other units. And, if this can be done without undoing the progress made using Safety I concepts.

Citation: Merandi J, Vannatta K, Davis JT, McClead RE Jr, Brilli R, Bartman T. Safety II Behavior in a Pediatric Intensive Care Unit. Pediatrics. 2018 June: 141(6). Pii: e20180018.