There are several ways an individual patient, or less likely a clinical caregiver working in a healthcare system, can be harmed, in spite of best intentions and expertise. Some of the known types of harm to patients include diagnostic errors, medication errors including overprescribing, errors due to lack of care coordination within the healthcare systems, and harm from transmission of pathogens in the healthcare system. About 400,000 harm events are estimated to occur in U.S. healthcare systems, including ~722,000 healthcare-associated infections every year. Some of the known types of harm to caregivers include occupationally-acquired infections, back injuries, and emotional exhaustion and burnout.
In my career of over a dozen years, I have led or participated in several initiatives to reduce patient harm from infections, and some initiatives to reduce infection harm to caregivers. I have also participated in a fair share of morbidity and mortality reviews, root cause analyses, failure modes effects analyses, and discussions on just culture. In the course of making action plans and designing structures and processes in order to prevent patients and caregivers from being harmed, there is always a justifiable tension between individual responsibility and contribution to the error (“Did the patient do anything that might have enabled occurrence of the infection?”, “Did the caregiver do anything to contribute?”) and the contribution of the larger system (as in, “Did the work environment of the caregiver set him or her up for lapse(s) in care that might have led to the development of infection?”).
When we look at the big picture, our healthcare systems and our individual caregivers are far safer now compared to before. For example, per the CDC report that is available here, infections from indwelling central venous catheters are decreased by 50%, and infections after ten major surgical procedures reduced by 17% between 2008 and 2014. The last reported occupational HIV infection in a clinical caregiver occurred over fifteen years ago. There is far more awareness, education and training now on preventing harm to patients as well as to caregivers in our healthcare systems.
Against this backdrop, the occurrence of hospital-onset/ occupationally-acquired Ebola in a U.S. hospital was particularly painful to many healthcare epidemiology and infection control professionals including me. This occurred almost four years ago, but there hasn’t been enough objective, fair and balanced discussion on the topic, beyond professional safe spaces.
Assigning guilt, blame or shame or any individual after a safety event occurs is unnecessary, unproductive and unprofessional. There is universal agreement on that. Because individuals function within a healthcare ‘system’ that they are part of, what role does the system play in causing these harm events? A system in comprised of people, processes, and technology. That being said, one could easily argue that processes and technology are made by people. So, essentially, the system consists of everyone else other than the individual at the sharp end of the safety event. Then there are different levels of the ‘system,’ which often seems impersonal and impervious. Patient care units function as part of the hospital. Hospitals and clinics function as part of the health system. In turn, the different health systems function within the larger community, state, nation and the world. There are several organizational, socioeconomic, political and cultural dependencies between the different levels. The extent of interdependence is too obvious (and uncomfortable to some) in the case of infectious diseases. How could outbreaks of Ebola in African villages lead to occupationally-acquired Ebola in a healthcare worker providing clinical care in the United States?
To prevent patients and caregivers from being harmed in the course of routine clinical care, we take the approach of building stronger systems that make harm less likely to occur. Health systems that allow less harm to happen are characterized by high reliability, resilience and agility. Describing each of these attributes is beyond the scope of this discussion, but realistically, how many U.S. healthcare systems can confidently say they have all these attributes with respect to every possible error?
Here are some thoughts worth reflecting on. Some of these thoughts are original, and some are borrowed from colleagues in the field that I deeply respect.
- Healthcare is a human need and a natural consequence of globalization is that an outbreak in a remote corner of the world can lead to occurrence of infection in the U.S. We can never think, “It can’t happen here,” or “it won’t happen here.” We cannot take anything for granted.
- How many health systems in the country have done competency training (not just an online module with videos) of all their personnel on how to perform hand hygiene correctly, how to don and doff gowns, gloves, masks and other personnel protective equipment? Even with proper use of ‘protocols’ studies have shown that these PPE are not 100% protective. When worn for long periods of time, personnel, being human, develop fatigue, drop guard, and without knowing, can get contaminated. It is not personal failure. Teaching people how to work together in teams that prevent infections together requires a different type of training. Many health systems have not made sufficient investments in these types of training, and most likely are not in a position to invest in them.
- The materials that hospital personal protective equipment are made of are not 100% impervious. We are lucky that the pathogens are not as easily transmissible as we usually think.
- How many nurses and physicians in the U.S. are experienced in taking care of patients with voluminous diarrhea? In countries that see a lot of patients with this presentation, there are things like a ‘diarrhea bed,’ which is essentially a steel cot with a hole under the patient’s bottom. The caregiver places a ‘bucket’ underneath the hole, and as gross as this seems, it poses much less risk of exposure to the caregiver as opposed to placing a tube in the patient’s rectum to contain the diarrhea or having to clean up the patient each time he or she passes stool. At the time of changing this bucket for a clean one, bleach is added to it which makes it less infectious.
- Travel history taken in one part of the health system not being seen in another part of the same health system is not new in healthcare. Per the ECRI institute 2018 report, internal coordination of care is one of the top ten patient safety concerns in the U.S. Sensationalism by the media notwithstanding, many healthcare professionals in healthcare were not surprised and it could have happened in any hospital.
- Hospitals in the U.S. with special biocontainment units that provided care for patients with Ebola in 2014 have had years of training and drills and serious expertise. Infection control in other settings and in other hospitals is not as perfect.
- Despite scientific advances, there is a significant amount of true uncertainty and unrecognized complexity in medicine and public health, and lack of evidence base for some existing practices. We do not have enough honest communication of these uncertainties and complexities in public. Conversations related to these topics happen in hushed tones and in close, safe professional spaces.
- Tight standardization of care works well for concrete clear-cut common situations but not so well for rare events. Think about your last flight and not being allowed to take any fluid over 3 ounces past the security checkpoint. This process will prevent safety events related to fluids, but it won’t prevent a suicidal pilot from taking 150 passengers along with him, or an engine from failing mid-air. Standardization of processes does not prevent every variety of error, and there is a lot of role for individual and collective mindfulness, teamwork, collaboration and other human qualities.
- Experts in public health and healthcare epidemiology believe that improving collective infection prevention skills requires serious investments in hospitals, and that it is an unattractive, slow process that requires deep commitment.
Lastly, none of these thoughts is an excuse to not work towards better prevention processes in our hospitals and health systems, not just in the U.S., but in the entire world.