March 19, 2013
by Suzanne Bouffard
If you’re about to have heart surgery, the last thing you want to hear is that the operating room is unsafe. But that’s exactly what researcher Ayse Gurses has found – and many of the hazards aren’t caused by doctors or nurses.
According to an Institute of Medicine report published in 1999, between 44,000 and 98,000 people die each year of preventable medical errors. Fortunately, Gurses has some solutions.
In a study of cardiac surgeries in five well-respected hospitals, Gurses and her colleagues found patient safety hazards in a whopping 58 categories. The hazards included problems with the physical space of the hospital, like hand sanitizers that were difficult for doctors to reach and patients spending 20 minutes in transit from the operating room to the critical care unit because there was no dedicated elevator for them. Hazards also included breakdowns in staff communication and poorly designed medical devices that forced staff to create time-wasting and potentially dangerous workarounds.
What concerned Gurses most were problems in transferring patients from one unit to another, for example between the operating room and the intensive care unit (ICU). In four out of five of the hospitals her team studied, the operating room and the ICU used different brands of intravenous pumps for life-sustaining medications. That meant that staff had to change equipment, increasing the chance of errors. The reason? Hospital administrators had chosen less expensive pumps for the ICU to save money, without consulting doctors or nurses.
There is a breakdown in the system of care, says Gurses. “When an airplane accident happens, it’s usually not just pilots’ error. It’s usually a series of factors that cause the accident. It is the same in healthcare. We keep blaming the nurse or the doctor. But we need to focus more on the entire system rather than hand-picking people.” This is why, she explains, it is important to systematically identify and mitigate hazards, because they can ultimately combine to cause a bad outcome for patients.
To improve patient safety, she says, “You have to redesign the system.”
Gurses is doing just that. An engineer who specializes in human factors and ergonomics, she and her colleagues at Johns Hopkins are creating new ways to improve patient safety. She and her team train operating room and ICU staff to work together, design patient safety checklists, and help hospital administrators coordinate equipment purchasing across units. She believes that the tools her team is creating can help all hospitals, even those that don’t have professionals like her on staff. But, she says, medical device makers and technology companies must make improvements, too. “After all, we are all responsible and accountable to improve patient safety,” she says.
What can patients and their families do? Gurses says that the first and most important thing is to advocate for yourself. “When you see something that doesn’t seem right, like a provider who doesn’t wash their hands when they should, say something. Or ask for the nurse manager of the unit. Never hesitate to speak up. Your safety should always be their number one priority.” And respond to hospital surveys, she counsels, because “hospitals do pay attention to the results.”
She says it’s also important to be active in your own care. When choosing a hospital, ask questions about safety procedures and about plans for post-operative care. And be sure to share information relevant to your care with every member of the care team. “Don’t assume the information will get from one clinician to another accurately and completely,” she says.
Ayse Gurses was recently honored with the Federation of Associations in Behavioral & Brain Sciences (FABBS) Foundation Early Career Investigator Award during the International Symposium on Human Factors and Ergonomics in Health Care.
