Team building is a popular health trend. It promotes cooperation, trust and respect, improves communication and improves patient outcomes. Most of the time.
But the camaraderie and familiarity of working with the same group of people can lead to an unappreciated risk to patient safety – a breakdown in standardized communication protocols based on misplaced mutual trust. Working daily with the same team of highly qualified colleagues impresses us and encourages us to let our guard down and skip steps in defined processes. In the world of risk assessment and mitigation, this phenomenon is known as a human risk factor.
Standard health care procedures draw inspiration from the disciplined field of aeronautics. Cockpit protocols are step-specific behaviors written down as a checklist and audibly confirmed by another team member. No matter how many flight hours a pilot and co-pilot have accumulated, each time they prepare to take off or land, they methodically perform the required exercise. Without exception. Who of us would feel safe on a plane if we were told the cockpit chose to skip the checklist that day?
Universal “time-out” protocols in operating rooms are a good example of using the required behaviors from the checklist. No surgery should begin without first taking the time to confirm aloud, in the presence of the entire OR team, the identity of the patient, the nature of the surgery and the specific surgical site. And it works almost all the time, unless the OR is running late and the surgeon is trying to skip the “time out”. It takes a strong, confident nurse to speak up and challenge a time-pressed surgeon. After all, the surgeon is probably very experienced, and the right patient and the right procedure has probably already been confirmed in the preoperative area by another nurse, unless he was also pressed for time.
Preoperative sponge counts by two nurses (or a nurse and a cleaning technician) are necessary to ensure a correct baseline count before surgery begins. During the intervention, each sponge brought into the operating field is recorded on a table, and a count of the sponges used is reconciled at the end of the intervention before closing the patient. Of course, the whole process fails if the initial count was inaccurate. The first experienced nurse had performed the exercise hundreds of times without error, so there was probably minimal risk when the second required person escaped to perform another necessary pre-surgical task. Nobody ever made a mistake, did they?
The administration of potentially dangerous medications requires the presence of two health care providers for review to confirm that the correct patient is receiving the prescribed medication at the correct dose. Occasionally busy vendors who trust themselves to get the job done right dispense with proofreading. What could go wrong if a newborn in the neonatal ICU received an adult dose or another baby’s potent drug?
As a risk manager who studied several examples of each of these scenarios, the common thread was that a skilled team member trusted an experienced colleague known to do the job right. Usually because the team member felt time pressure to complete other tasks. In the rush of the moment, the communication protocol was rationalized as unnecessary and “probably safe this time”. What the field of risk assessment and mitigation reminds us is that communication protocols exist for a reason. We are all human; all human beings make mistakes.
Michael J. Grace is a lawyer and author of The Mumbo Jumbo Fix: A Survival Guide to Effective Doctor-Patient-Nurse Communication.