Channeling Florence Nightingale to Promote Patient Safety

Colin T. Son


June 23, 2009

The 2000 Institute of Medicine (IOM) report, To Err Is Human , asserted that more than 44,000 patient deaths a year in the United States were attributable to medical errors. At the time, it was a shocking figure. For many healthcare professionals, and certainly for the lay public, the report sparked a growing consciousness about patient safety and medical errors.

Not for Barbara Olson. A nurse with a passion for patient safety, she consults and writes widely about patient safety. Her background includes a fellowship at the Institute for Safe Medication Practices (ISMP), a national organization devoted to preventing medication errors. Ms. Olson writes about patient safety at her blog Florence dot com, as well as on Medscape at On Your Meds: Straight Talk About Medication Safety. I recently asked her to discuss the continuing uphill struggle to end preventable medical errors.

Colin Son: Pretend I know nothing about medical errors besides the statistics from the IOM report. What are the goals of patient safety and medical risk management?

Barbara Olson: It's funny that you should start with a mention of the IOM report, because that was such an important touch point for seasoned clinicians, one that I think allowed the specialty of patient safety to emerge from the shadow of its rather stern, secret-keeping aunt, risk management. Being a plain spoken individual, I like Wikipedia's current definition of patient safety:

A new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error[s] that often lead to adverse healthcare events.

Risk management remains somewhat different, necessarily focusing on practical issues that include patient safety but must also account for standards and statutes that do not always align with key elements -- like nonpunitive error-reporting and disclosure -- that advance patient safety.

When it comes to goals, I think it depends who you ask and what their stake is. The outcomes that have been achieved in the 10 years since To Err is Human are disappointing, certainly when benchmarked to the original challenge goals (to reduce preventable medical errors by 50% in 5 years). But in the United States, we're having to take a nonlinear path, one that addresses systemic problems -- like how emergency rooms doubling as primary care sites diminishes the effectiveness of care -- before we'll see meaningful gains in the "patient safety" column.

The Health Care Blog hosts Grand Rounds
June 22, 2009

Colin Son: What are the tools we have to work with in improving patient safety?

Barbara Olson: I think the 6 dimensions of care -- safe, effective, timely, efficient, patient-centered, and equitable -- defined in the IOM's Quality Chasm report remain hugely valuable for keeping key issues on the table, indexing them, identifying next steps, and following progress in a "big-picture" way, whether you've been at this for a long time or are just becoming aware of the deficits. The journey is longer and rockier than expected, but the map is fine. (I keep a hand-written index card with the IOM's Big 6 on my desk.)

Most seasoned healthcare workers came to their profession with a desire to combine wage earning with meaningful work. But we came up in traditions that were largely intention-oriented. We heard, repeated, and took to heart things like "First, do no harm" and "Follow the 5 Rights" without pausing to realize that these are broadly stated goals, not operational steps for achieving them. I see patient safety as the process our intention-based healthcare culture is undergoing in order to grow up and become the reliable entity we know it can become.

I think it's important to engage the front line if we're seeking to create a culture in which patient safety is paramount. And we'll need far more reliable tools, certainly better usability from high-end information technology (IT) solutions than the ones we have. (I recently wrote a post about using the American Recovery and Reinvestment Act funds to improve healthcare IT entitled, "Meaningful Use: Don't Pee on My Leg and Tell Me It's Raining".)

I also think healthcare professionals need education that includes the science of quality measurement and -- this is my particular area of interest -- knowledge that will allow people on the front lines of care to be active participants in adapting principles and practices used in high-reliability organizations to strengthen the processes we use to deliver care. It's not about adopting these principles, it's about adapting them, and you can't figure out what that looks like when you're too far from the patient.

Colin Son: What's your experience in patient safety? Can you give us some examples of how you've translated your patient safety interest into your clinical role?

Barbara Olson: In the mid-90s, I served on a jury that heard a chipper-shredder mishap case. That's when I first learned that principles of good design include accepting that humans will do things they are not supposed to do, sometimes by intent and sometimes through simple human error. I was struck by how different engineering standards were from what I was advancing as a nurse leader on a large, urban, maternity service (where I was involved in both work-flow design and deconstructing adverse outcomes). We were all about educating people and reinforcing desirable behaviors and progressive discipline and things like that.

A few years later, To Err is Human was published. And I remember going to a conference in Philadelphia in 2001, shortly after release of Crossing the Quality Chasm, where I heard Mary Wakefield and others discuss the call for healthcare system overhaul. Almost everything I heard about medical errors and system-level approaches to get at them made intuitive sense. It was stuff your average Walmart shopper would understand. But errors were things that, in my experience, simply hadn't been spoken of in public health terms before. I remember telling a colleague who hadn't attended, "Looks like we're finally going to be able to talk about the elephant in the room with the door open."

I didn't turn my career to patient safety until later, when I got good and tired of seeing the same problems over and over: urban settings, rural settings, maternity, emergency departments, med-surg, computerized, not-computerized. It's not that what I did didn't work; it just didn't last. You know the expression, "Same stuff, different day." Patient safety, as a discipline, was a place to take my knowledge and experience and seat them in a different construct.

I was fortunate to be able to undertake a 1-year fellowship with the Institute for Safe Medication Practices, studying what I call "the science behind the compliance." At ISMP, I learned specific strategies for mitigating risks associated with medication use. More importantly, I learned universal risk-reduction principles and how to link my work with others'. I now educate and consult, mostly for healthcare entities, clinicians, and industry stakeholders, to advance systems-thinking and help translate it to clinical settings. I also maintain a close relationship with ISMP, serving as a reviewer for their publications and as an advisor for, ISMP's consumer website.

Colin Son: "Florence dot com" is named after Florence Nightingale. Beyond serving as the founder of modern nursing, how is she connected to quality assurance and patient safety?

Barbara Olson: I joke that I channel Florence Nightingale, but I doubt she'd like everything I say. I named my blog-as-patient-safety-primer after her for a couple of reasons. First, Florence Nightingale did things that reached ordinary people and made a difference in their lives. That's how I try to come at things. And because Nightingale had a broad liberal arts education, she was able to problem-solve from a wide base of knowledge that tapped economics, statistics, and an understanding of human behavior. Nursing really is rooted in this tradition. The post-World War II "nurse as doctor's helper" figure kind of derailed the image of nursing as a public health discipline, at least in the public's eye. I think the discipline of "patient safety" is really just another incarnation of Nightingale's vision.

"Florence dot com" is one way clinicians, at all stages of their careers, can gain fluency with the core principles used to advance patient safety. Since it's a personal forum, I do it in ways that interest, or at least amuse, me. (It's a relatively untested approach -- at least for this topic -- but I like to think I'm one federal grant away from proving that my post "Jon and Kate: I Think I'll Medicate!" actually promotes adoption of safe medication use practices.) And I know for certain that my mother enjoys reading it.

This week we're fortunate to have Barbara Olson hosting Grand Rounds, a collection of posts from a variety of medical bloggers. "Florence dot com" will take a break from the world of patient safety to take readers on a tour of the medical blogosphere. I encourage you to check it out.