Recently, a man and his daughter came to see me in my office. They were upset because their wife and mother had fallen and broken her hip while an inpatient at GBMC. She had come in for an elective surgical procedure and was a bit disoriented post-operatively. A unit staff member had helped the patient out of bed in the middle of the night and had then assisted her back into the bed. Sometime later, the patient tried to get out of bed again to visit the bathroom and fell, fracturing her hip. It seems that the staff member who helped the patient out of bed had forgotten to reset the bed alarm so that when the patient got up on her own, the alarm did not sound and the staff was not alerted to the impending danger. The staff had correctly identified this patient as high risk for falls and had the appropriate equipment for fall prevention in the room.
Reliability means what should happen, happens, and what should not happen, doesn't. In this case, a woman under our care fell and sustained a serious injury. This should not happen. But why did it happen and what should we do to make sure it doesn't happen again?
Our Falls Team has dramatically reduced the number of falls at GBMC. Preventing falls in the hospital, especially among the physically compromised, is very difficult. It requires vigilance among the staff, and standard work using evidence-based care to do this. One miss, as in this case, can cause serious injury. Until a few months ago, we had high defect rates in the use of all of the important safety devices (alarms, socks, wrist bands, and signage) on some days on some floors. Now, it is very unlikely that a high fall risk patient doesn't have all of the equipment in place. But even with the equipment in the room, most of our beds have alarms with a design flaw: to take a patient out of bed safely you first shut off the alarm, and when you put the patient back in the bed you have to remember to turn the alarm back on.
These bed alarms are examples of active safety devices. The problem with such devices is that they require an action on the part of a human to operate correctly. But humans are not perfect and they sometimes forget, especially when busy caring for many patients at once. If our nurses care for 80 patients a day with bed alarms, and the patient gets out of bed five or six times a day, that’s almost 500 times a day the staff must remember to reset a bed alarm. Our nurses and technicians work so hard it is easy to see how one of them could get distracted and forget to reset the alarm. But if we get it right 499 times out of 500, and the one time we miss results in a patient injury, we still have to find a way to get to perfection.
In the old days, our reaction here would have probably been to reeducate the staff on the importance of resetting the alarm. This action is silly at best. When our staff gets something right 99% or more of the time, is it that they don’t know that they should reset the alarm? Of course not, it’s that they forgot, so education is not likely to fix the problem.
High reliability organizations search for passive safety devices – ones that don’t require human action and therefore are much less likely to fail. As a pediatrician who has treated a number of drowning victims, I recall when gates in fences around pools used to require an adult to remember to pull the gate shut to keep young children from wandering into the pool area unattended. Now, most pool gates have a spring that pulls the gate back into the closed position and a self-catching lock…the gate shuts itself after someone enters. Our falls team recognized that even the smartest, hardest-working staff member will eventually forget to reset the bed alarm. GBMC is now beginning the replacement of our beds and purchasing new beds that have alarms that reset automatically. We now have a number of these beds already in place. In the interim, the Falls Team continues to test ways to “catch” that someone has forgotten to reset the alarm.
To err is certainly human; but as humans and as healthcare leaders, we have the ability to redesign our systems so that common human errors are blocked or mitigated before they cause harm. We must study every event and find new ways to make our GBMC HealthCare system safer every day.
Let me thank everyone in the GBMC family for helping us get to higher reliability and closer to our vision.