Nurses hesitate to challenge doctors even when doctors are ordering the wrong drug or operating on the wrong limb.
By LAURA LANDRO-Wall Street Journal
When it comes to safety, the aviation industry has it down to a science, compelling pilots to go through checklists before takeoff and relying on every crew member, regardless of rank, to work as a team and report dangerous lapses. But in hospitals there is no such fail-safe system, one reason that tens of thousands of American patients annually are harmed or killed by preventable infections, wrong-site surgeries and medication mishaps.
A few years ago, after seeing a toddler die from substandard care, Peter Pronovost, an anesthesiologist and critical-care specialist at Johns Hopkins Hospital in Baltimore, set out to change the way that hospitals function. In "Safe Patients, Smart Hospitals"— co-authored with Eric Vohr, a former Hopkins media-relations executive—he makes a compelling case for shaking up an archaic and often "toxic" medical culture.
Too often, Dr. Pronovost writes, doctors "think they are infallible, communication between nurses and doctors is poor and accountability is virtually non-existent." He notes that doctors aren't trained to listen to nurses, family members or anyone else for that matter. "Medicine operates like a private club of self-styled deities where the entrance requirement is an M.D."
Dr. Pronovost proposes a two-fold strategy for bringing health care closer to the standards of aviation: simple, rigorous checklists designed to deliver proven treatments and procedures; and a cultural makeover aimed at tearing down the traditional hospital hierarchy that makes nurses afraid to challenge doctors even when doctors are ordering the wrong drug or operating on the wrong limb. Hospitals need a collaborative model, Dr. Pronovost says. Members of a medical team need to work like flight crews to redesign flawed systems of care.
Not that making such changes will be easy. Whereas pilots learn to fly a few basic planes and must remember a set of controls and checklists that rarely change, doctors must retain vast amounts of information, and the information itself is constantly undergoing refinement and revision. In aviation it has long been accepted that humans are fallible; flight crews, for instance, must go off-duty after they reach a work-hour limit. By contrast, doctors are trained to work punishing hours; sleep deprivation is a badge of honor; and, as Dr. Pronovost writes, "there is difficulty admitting that well-meaning, highly trained, competent doctors predictably and continuously make mistakes."
In the course of advancing his argument, Dr. Pronovost offers glimpses into the harrowing world of intensive care, such as a patient accidentally left to overdose on narcotics—saved, ironically, because he was a heroin addict and could tolerate the excess of drugs. In one heart-stopping scene, Dr. Pronovost faces off with a surgeon who refuses to admit that the patient on the operating table is having a deadly allergic reaction to the latex gloves that the surgeon is wearing.
Dr. Pronovost had his first inklings of medical fallibility when his own father was diagnosed with cancer—just not the kind he actually had, which resulted in worthless treatments that fatally delayed the care that might have saved him. But Dr. Pronovost's epiphany came with the death of Josie King, an 18-month-old who was brought to Johns Hopkins in 2001 for burn treatment and ended up dead because of hospital error. Her mother, Sorrel King, recounted that tragic tale in her own book, "Josie's Story," reviewed in these pages last year.
One obvious target for improved care is in the use of so-called central-line catheters. Inserted into veins in the neck, chest or groin, the catheters administer medications and fluids and sometimes measure blood volume. Though they regularly save lives, each year roughly 80,000 patients in the U.S. get central-line infections, many linked to failure to follow preventive measures, and 30,000 to 60,000 die.
The guidelines from the Centers for Disease Control and Prevention for preventing central-line infections run to 120 pages, hardly a handy reference. Dr. Pronovost has distilled the guidelines down to a five-step checklist for doctors and nurses: wash hands; use sterile gowns, gloves and masks; clean the insertion site with antiseptic; avoid placing catheters in the groin (where infection risk is higher); and remove a catheter as soon as it is no longer needed. In a federally funded program, 50 intensive-care units in Michigan hospitals followed the checklist. Infection rates dropped to nearly zero and stayed there, saving an estimated 2,000 lives.
But it is hard to disturb the status quo. As he travels around the country urging his message of reform, Dr. Pronovost has often found that hospitals want to do things their way and don't rigorously collect data; chief residents don't want to follow his proposals to let nurses accompany them on patient rounds; and surgeons resent interference.
When a particular hospital culture proves resistant to change, Dr. Pronovost devises workaround strategies, such as giving nurses pagers to summon hospital executives if a doctor's intransigence threatens safety, or setting up a Web site where staffers can anonymously report problems. Dr. Pronovost acknowledges that he can come off as a caped crusader, rubbing his peers the wrong way. He tells of one case where a nurse was afraid to tell a surgeon that he had to keep a patient in the operating room longer because the intensive care unit was overwhelmed. Dr. Pronovost stepped in and took the heat from the screaming surgeon, who didn't want to lose the next paying case. But hospital profits are clearly not Dr. Pronovost's first concern at the moment. Safe patient care is.
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