High Reliability: It’s Hard to Get to Zero

By now, most people in health care understand that safety is a system characteristic and that we owe it to our patients to not create harm when they come to us for care. Many people now understand that we operate in a large, complex system and that the system is full of “latent” errors like not knowing what the evidence says is the best care or not following protocols when we do.  When these latent errors align….a patient gets hurt. What those of us who work on this every day now know is that it’s really hard to drive out all of the latent errors in the system. It is really hard to get to zero injuries to patients!

So, when we do get to zero in some area of harm, it's really a cause for celebration. GBMC, our beloved medical center, has now gone 6 months without a single central-line associated blood stream infection! This is phenomenal news. Some hospitals only measure this for central lines in patients in intensive care. We measure this for all patients on all units. As the run chart below shows, as recently as August of 2014, we had a rate of 3.5 infections for every 1,000 patient days with a line in place.

We did not get to this outstanding performance by wishing or hoping. We got there by making a commitment to get to zero and by filling the holes in the “Swiss cheese” - that is, by making sure that we found the weaknesses in our defenses against the central line seeding bacteria into the bloodstream. We have always had excellent doctors, nurses and other clinicians and they really cared and worked hard but we were not always acting according to the evidence on how to avoid these infections. So, we created standard evidence-based work for inserting a line and we audited our performance to make sure the standard work was being followed. We created standard work for how the lines were used and maintained on a daily basis and we checked to see that this work was being followed as well. We also developed standard rules for assuring that the line came out as soon as it was no longer needed. Every time we had an infection, we studied the events to see if we could find the cause to root it out so that it could not cause a future infection.

Will we ever have another central line infection? We probably will because our systems are much better but they are not perfect and we still have humans working in health care. Our people are very smart and work very hard but they are sometimes distracted. There are also uncommon “special causes” that arise that are beyond our control – like the rare patient with mental illness who was purposefully contaminating a line. But I am so proud of our team for the outstanding accomplishment of 6 months without a CLABSI. Zero – 100% reliability - is hard but it is not impossible.

Our patients do not usually thank us for not harming them (when was the last time you thanked a pilot for not crashing your plane when it landed) but let me thank all of our clinicians for getting us closer to our vision.