Only acceptable measure: zero patient harm

Published on Tuesday, March 12, 2019

By: Ruth Cummins

When it comes to University of Mississippi Medical Center patients developing infections or other harmful conditions after they’re admitted to the hospital, one episode is too many.

That’s the mantra of “Chasing Zero,” a new Medical Center initiative that strives to eliminate serious safety events impacting patients and to cultivate safer, more effective care. The proactive approach’s unveiling is today, with clinical staff getting details during two get-togethers sponsored by the quality team of Chief Medical Officer Dr. Michael Henderson.

“We’ve made a concerted effort to improve every single year by decreasing harm events,” said Dr. Phyllis Bishop, professor of pediatric gastroenterology and chief quality and patient safety officer. “But is it OK to just reduce harm events by 20 percent, or 50 percent, or 60 percent? Why is it OK ever to have any one of these events happen?

“There are harm events that we can prevent. Instead of saying it takes too long, or it’s too hard, the attitude should be that the only acceptable number for these events is zero.”

The initiative is modeled after “Zero Patient Harm is Achievable,” an effort championed by The Joint Commission, the nation’s leading accrediting body in health care. “We understand the steps that health care needs to take to get a lot better,” Dr. Mark Chassin, president and CEO of The Joint Commission, says in one of the Commission’s Chasing Zero videos.

“Our goal as quality improvement professionals is to get health care to the same degree of safety that high reliability organizations enjoy today - where zero harm is the natural byproduct of the way we take care of patients.”

Chassin also leads the Joint Commission Center for Transforming Healthcare, which strives to turn health care into a high reliability industry by developing effective solutions to health care’s most critical safety and quality problems.

Safety events occur about once a day, on average, at the Medical Center. Examples include infections that develop on a surgical site and pressure ulcers suffered by patients when there’s pressure on a specific area of the body for a prolonged period.

The Medical Center’s campaign will initially focus on six specific serious safety events that occur less frequently:

• 

  Wrong patient, site, or procedure
• Unintended retained foreign body
• Medication error resulting in death
• Fall (inpatient or outpatient) resulting in serious injury or death
• Irretrievable loss of irreplaceable tissue specimen
• Administration of wrong blood product

The Chasing Zero mindset is similar to that in many industries that post the number of days since a work injury occurred. The Medical Center’s six serious safety events will be monitored as a group hospital-wide.

“We’re going to count up the days that we go in a row without having any of those six things occur,” Bishop said. “If one of them happens, we have to go back to zero days. We want to see what kind of safety streak we can have with zero.”

Chief Nursing Officer Dr. Terri Gillespie is responsible for setting the safety tone for the Medical Center’s approximately 3,000 nurses. This campaign must be different, she said.

“Research has shown that when patients are admitted to a hospital, their expectation is that we will do no harm,” Gillespie said. “Research also shows that developing an infection is one of their top 10 fears. We need to live up to their expectation of doing no harm, and to alleviate any fears.”

Chasing Zero is being introduced here as the nation observes Patient Safety Awareness Week March 11-17. It’s a time to increase awareness about patient safety among health professionals and the public.

Employees taking part in today’s get-togethers will see the “Zero Patient Harm is Achievable” video featuring Chassin. They’ll receive reminders of chasing zero, such as Zero candy bars, hard candies shaped like a zero, and Coke Zero “to remind people that the only acceptable number for these events in our institution is zero,” Bishop said.

The Institute for Healthcare Improvement said last month that a recent national survey conducted by organizations including the IHI and the Lucian Leape Institute found that one in five people surveyed reportedly experienced a medical error in their own care. The study found that one third of those surveyed reported an error in the care of a close relative or friend. Of those who experienced errors, 73 percent said the error had a long-term or permanent impact on the patient’s physical health, emotional health, financial well-being, or family relationships.

Chasing Zero is a term that’s been used nationally for some time. Following the near-death experience of his newborn twins from a medication error, actor Dennis Quaid hosted and narrated the 2010 patient safety documentary “Chasing Zero: Winning the War on Healthcare Harm” on the Discovery Channel. It chronicles families affected by medical errors, including the family of Quaid after his twins received a massive heparin overdose.

In November 2015, Chassin visited the Medical Center at Henderson’s invitation to bring home the need for quality improvement and error prevention at all hospitals. Chassin toured University Hospital, including the Emergency Department, and spoke during Grand Rounds about high reliability in health care.

He posed this question: If someone on a transplant surgical team noticed that a patient's healthy left kidney was about to be removed instead of the diseased kidney on the right, should catching such a close call be considered a victory?

“Someone saved the day, but let's not celebrate too hard,” Chassin told his audience.

“It happens over and over,” he said of incorrect medication distribution, failed communication on transfer of care from one front-line staff to another, and failed hand hygiene leading to infection. “We have to look at how we've been approaching this. What we're doing is not getting us close enough to zero.”