The natural lifespan of a safety policy: Violations and system migration in anaesthesia

Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France.
Quality and Safety in Health Care (Impact Factor: 2.16). 03/2010; 19(4):327-31. DOI: 10.1136/qshc.2008.029959
Source: PubMed


Safety rules continue growing rapidly, as if constraining human behaviour was the unique avenue for reaching ultimate safety. Safety rules are essential for a safe system, but their multiplication can have counterproductive effects.
To monitor, in an anaesthesia ward, compliance with a process-oriented safety rule, and understand barriers and facilitators which help and hinder physicians from following guidelines.
The rule stipulated that the day before surgery anaesthetists had to record in the patient's file the drugs to be used for the anaesthesia (induction, maintenance, airway control). Compliance was assessed before introduction of the rule, immediately after, at 6 months and at 12 months. All medical staff were blinded to the protocol.
717 patient records were included. The results showed an initial compliance with policy, reaching 86% for some items (never 100%). Reduction began within 6 months and returned almost to initial levels within a year. One individual showed poor compliance throughout the study but even initially compliant doctors experienced a reduction. Compliance was higher for complex surgery but lower for unscheduled surgery and when job pressure was greater.
Compliance eroded over time. A major trigger of erosion seemed to be lack of continued compliance by a senior member of staff. Rules and procedures constitute fragile safety barriers, and it may be better to forego introducing a new safety rule if it is not considered as a priority by staff and is therefore vulnerable to sacrifice in case of conflict with competitive demands.

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    • "A recent study demonstrated the positive impact on handwashing hygiene of the behavior of senior clinicians as positive role models [33], and there is potentially a cumulative effect on practice once role models (both senior and junior) start to implement guidelines. Finally, the non-compliance of senior role models has led to the erosion of compliance among other physicians [34]. "
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    ABSTRACT: Aseptic technique and handwashing have been shown to be important factors in perioperative bacterial transmission, however compliance often remains low despite guidelines and educational programs. Infectious complications of neuraxial (epidural and spinal) anesthesia are severe but fortunately rare. We conducted a survey to assess aseptic technique practices for neuraxial anesthesia in Israel before and after publication of international guidelines (which focused on handwashing, jewelry/watch removal and the wearing of a mask and cap). The sampling frame was the general anesthesiology workforce in hospitals selected from each of the four medical faculties in Israel. Data was collected anonymously over one week in each hospital in two periods: April 2006 and September 2009. Most anesthesiologists received the questionnaires at departmental staff meetings and filled them out during these meetings; additionally, a local investigator approached anesthesiologists not present at these staff meetings individually. Primary endpoint questions were: handwashing, removal of wristwatch/jewelry, wearing mask, wearing hat/cap, wearing sterile gown; answering options were: "always", "usually", "rarely" or "never". Primary endpoint for analysis: respondents who both always wash their hands and always wear a mask ("handwash-mask composite") - "always" versus "any other response". We used logistic regression to perform the analysis. Time (2006, 2009) and hospital were included in the analysis as fixed effects. 135/160 (in 2006) and 127/164 (in 2009) anesthesiologists responded to the surveys; response rate 84% and 77% respectively. Respondents constituted 23% of the national anesthesiologist workforce. The main outcome "handwash-mask composite" was significantly increased after guideline publication (33% vs 58%; p = 0.0003). In addition, significant increases were seen for handwashing (37% vs 63%; p = 0.0004), wearing of mask (61% vs 78%; p < 0.0001), hat/cap (53% vs 76%; p = 0.0011) and wearing sterile gown (32% vs 51%; p < 0.0001). An apparent improvement in aseptic technique from 2006 to 2009 is noted across all hospitals and all physician groups. Self-reported aseptic technique by Israeli anesthesiologists improved in the survey conducted after the publication of international guidelines. Although the before-after study design cannot prove a cause-effect relationship, it does show an association between the publication of international guidelines and significant improvement in self-reported aseptic technique.
    Israel Journal of Health Policy Research 03/2014; 3(1):9. DOI:10.1186/2045-4015-3-9
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    • "There are many reasons for this. Physicians worry about possible litigation after disclosure of medical errors, do not clearly understand the definition of an AE, often consider that the circumstances of a case or its outcome do not warrant reporting, do not believe that reporting will lead to improvement, and, last but far from least, do not see what added value the growing body of quality and safety guidelines provide in terms of patient outcomes [9] [14]. They identify no direct link between the rules and the risk for the patient, with the result that compliance with many rules is eroded. "
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    ABSTRACT: The performance of patient safety initiatives has not met expected targets for reasons that are gradually being understood. They have been too hospital-centered and too process- and "silo"-driven in their search for the causes of adverse events (AEs). Information technology could help overcome many obstacles, but only if the tools developed are based on a relevant safety model. We have applied the distinction between easy, complicated, and complex problems and strategies in healthcare to changes that need to be made in the detection and analysis of AEs. We propose a triple shift: (i) adopting an outcome-driven rather than a process-driven policy when defining and counting AEs (relatively easy), (ii) applying a patient- and not silo-driven approach and extending the timeframe when analyzing AEs (more difficult), and (iii) taking a systemic view of all care delivered to a patient during their life-span in order to erect barriers against the risks identified (highly complex).
    Journal of Biomedical Informatics 08/2009; 44(3):390-4. DOI:10.1016/j.jbi.2009.06.004 · 2.19 Impact Factor
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    ABSTRACT: To provide recent evidence of safety in anesthesia and appraise the role of established tools of safety improvement in anesthesia practice. The current incidence of minor events or complications during anesthesia is estimated at 18-22%, for severe complications 0.45-1.4%, and for mortality of 1: 100 000. Evidence suggests that despite such low complication rates, further improvements can still be made by addressing systemic factors which are known to set up conditions for adverse events. In particular, improvements can be made in the areas of drug errors, and inadequate or lack of communication between different clinical teams during the process of handovers. In addition, the evidence is growing which highlights the importance of established tools such as critical incident reporting, quality management using plan-do-check-act cycles, use of checklists and use of simulation in training clinical staff in the areas of nontechnical skills. Anesthesia is one of the safest clinical specialties and remains at the top among leaders of patient safety. This review provides evidence for the areas in which further progress can be made, and usefulness of certain tools, such as critical incident reporting, checklists, plan-do-check-act cycles and simulation, can be used for continued improvements.
    Current opinion in anaesthesiology 02/2011; 24(3):349-53. DOI:10.1097/ACO.0b013e328344d90c · 1.98 Impact Factor
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