This past week, Vox published a series of articles by Sarah Kliff as a part of its year-long examination of fatal medical harm. The "Do No Harm" essays explore hospital-acquired infections and the patients they effect. We urge everyone to read and share this series. We'll explore three takeaways in today's post.
1. The airplane crash vs. car crash mentality
Airplanes crash very rarely, but when they do, airports and planmanufacturers immediately analyze the accident to identify the problem and rectify any procedural or mechanical errors that led to that disaster. As the author of the series points out, "one-off events just don't exist. Airplane manufacturers treat each crash as potentially preventable and work backward to figure out how it could have been prevented."
In contrast, cars crash frequently, killing far more individuals than do airplane disasters. The mentality of car manufacturers and safety regulators is not to examine each accident with intensity, but rather to look for patterns that may reveal a problem that needs to be corrected. They acknowledge "some accidents are unavoidable, no matter how much work goes into prevention."
With regards to central line infections, there are car crash hospitals and there are airplane crash hospitals.
2. 5 steps can eliminate central line infections
After a central line infection claimed the life of 18-month-old Josie King, a Johns Hopkins University critical care physician examined all the recommended steps to prevent these harmful infections and ranked them, selecting the 5 most critical steps. This checklist of "obsessive, meticulous cleanliness" had to be backed up by proper supplies and training, but the most important shift was cultural: The hierarchical structure of doctors and nurses which made public reminders to follow the checklist difficult at first. But the results were astounding: Central line infections went down 70% - first at Johns Hopkins, then at the 100+ hospitals where the checklist was employed.
3. Hospitals must accept that central line infections are not inevitable
When a medical error results in patient harm, it is the hospitals responsibility to treat this error like a plane crash - preventable, avoidable, and requiring intense scrutiny - and not like a car crash - sad but inevitable. This response not only helps mourning loved ones, it also provides an opportunity to identify a systemic problem and correct it. To accomplish this goal, the hospital culture must shift from a culture of blame to a culture a responsibility.
FURTHER READING
Read the full Vox article here.
To read more about the culture of responsibility rather than the culture of blame, please visit The Josie King Foundation website.
For more information on howto avoid contracting an HAI, please check out our post here.
Stay tuned for more reviews of the Vox series on fatal medical errors.
