Patient Safety Zone

Many health care professionals feel that they have little influence and are too inconsequential to make a difference.

The initial feeling of helplessness is understandable given the extent of the patient safety problem and the scale of the national improvement initiatives we described - fortunately it is wrong.

There are many basic ways in which you can contribute to patient safety every day, for example:

• Communicate clearly
• Follow guidelines and protocols
• Be an effective team member
• Remain vigilant
• Look after your own health, happiness and safety
• Raise concerns appropriately
• Report and learn from patient safety incidents

Communicate clearly

Clear communication - with patients, colleagues and in medical records - is one of the most important contributions that any health care worker in any setting can make to improve patient safety.  

There are a number of methods that can help you to communicate clearly, for example:

• Check for understanding (also called a ‘read back’): check that you have communicated clearly, by asking colleagues or patients to summarise their understanding of what you said
• Structure the information that you wish to communicate.  There are various techniques to facilitate this, for example SBAR.
• Listen to the patient

Effective communication also implies that error and error frequency should be acknowledged openly.

The SBAR technique

SBAR is a communication technique adapted from the US Navy.  It helps health care professionals to structure the information they are trying to communicate to a colleague.  The acronym stands for:

S = Situation
B = Background
A = Assessment
R = Recommendation

For example, a junior doctor caring for a post-operative patient in a surgical ward is concerned.  She phones a senior member of her team:  
‘…Hello.  I’m dr. X, phoning from Ward Y about patient Z (Situation).
She had a laparotomy after a failed laparoscopic cholecystectomy this morning (Background). Her pulse is now 110 and her blood pressure is 110/60 (Assessment). I am going to infuse a further 500 ml of Saline and would appreciate it if you could check on her in the next hour (Recommendation)...’

Raise concerns appropriately

You have a moral and professional duty to speak up if you consider a patient to be at risk.  However, this should be done in an appropriate manner, time and place. You should also report unsafe working conditions, close calls, and adverse events. 

Follow guidelines and protocols

Protocols and guidelines help to standardise care and protect against error.  The quality of protocols and guidelines vary, some may be time-consuming, unclear or may not seem to directly reduce risk.  However, deliberate non-compliance (a violation) potentially exposes you, your colleagues and patients to preventable risk.

Examples of general process protocols that are widely used in clinical settings:

• Use at least two separate patient identifiers to confirm a patient’s identity before commencing an investigation or treatment.
• Physiological alarm systems should not be ignored or inappropriately inactivated
• Hand hygiene protocols are now in place in most settings.

Be an effective team member

Drawing on the specific expertise of each team member can be a valuable resource.

Team members also act as additional defences to help detect errors and prevent harm.  Think of them as additional slices in the Swiss cheese model.

Remain vigilant

There are a number of strategies that may help you to maintain vigilance:

• Use risk assessment tools in preference to subjective judgement where possible as part of patient care.  One example is the Well’s DVT scoring system in preference to a ‘gut feel’.
• Risk assessment should be a regular, routine part of clinical care, in preference to opportunistic screening.  For example, reviewing the indication for anticoagulation at every morning ward round.
• Learn to recognise and confront ‘drift’.  Drift is the incremental accumulation of violations.  It can often be observed as ‘cutting corners’ once health care professionals have ‘settled in’

Look after yourself

• Assess your own vulnerability to risk.  The three buckets approach may help (module ‘Managing human error’).
• Allow the necessary time and relaxation to remain safe
• Remember that needing, requesting and accepting support is not a sign of weakness.

The following references were used to generate content for this section:

Cretikos M, Parr M, Hillman K, et al. Guidelines for the uniform reporting of data for Medical Emergency Teams. Resuscitation. 2006; 68:11-25.

Frankel A, Leonard M, Simmonds T, et al. The Essential Guide for Patient Safety Officers. Chicago: Joint Commission Resources with the Institute for Healthcare Improvement; 2008.

Rosekind MR, Gander PH, Gregory KB, et al. Managing fatigue in operational settings: An integrated approach. Hospital Topics 75. Summer 1997;31-35.

Root causes of sentinel events, all categories. Oakbrook, IL: Joint Commission, 2006.

Walton, MM. Hierarchies: the Berlin Wall of patient safety. QSHC 2006;15:229-230