Speaker(s): Steve Spear (HBS) & Anita Tucker (Wharton)
Title:
A case study of hospital nursing"
Abstract
Medical care in the United States is technologically advanced and at times,
almost miraculous: health care professionals can extend and improve quality of
life far beyond what could have been imagined only a generation or two ago. Yet,
along with success stories, the system creates tragedies as well-adverse events
that harm patients. Fifty thousand to 100,000 people are estimated to die each
year from medical error, and another 100,000 are estimated to succumb to
hospital-acquired infections. Non-fatal injuries are estimated at five to ten
fold the number of deaths with near misses occurring at rates five to ten times
that of injuries. In sum, entering a hospital entails risk beyond those imposed
by patients' underlying medical conditions.
Individual incompetence or malfeasance typically do not cause adverse events.
Rather, well-meaning, well-trained people find their best efforts compromised by
unreliable systems in which the whole is far less than the sum of the parts.
In response, recommendations to reduce adverse events focus on improving health
care system design, including information automation (particularly for
medication administration), medication packaging and labeling changes, data
bases of near miss events to motivate system changes, and "root cause
analysis" of sentinel events (after the fact investigation of why harm was
done, somewhat akin to a National Transportation Safety Board after-crash
analysis).
We propose that in addition to these efforts, patient safety can be improved
further by redefining assumptions and work patterns that underpin the delivery
of hospital care. Drawing on our extensive observation, interview, and survey
data from hospital nurses, we found several factors evident in nursing work that
might increase the rate at which errors and inefficiencies occur. Some of these,
as we discuss, may be inherent to meeting the needs of patients. However, many
factors are avoidable; they could be removed from the work system as a source of
risk if they were addressed. However, they are often times too small in
consequence (even though they occur with great frequency) to be picked up by the
various approaches listed above, such as reporting and traditional root cause
analysis. Based on this finding and understanding of how non-medical industries
achieve outstanding performance, we conclude with recommendations for improving
quality and safety in healthcare beyond those already broadly discussed.