Preface

Chapter 8 **Transfusion Error in the Gynecology Patient: A Case Review**

Carly Madison Hornis, R.S. Vigh, J.F. Zabo and E.L. Dierking

Derek Tang, Peter A. Dowbeus, Michael S. Firstenberg and Thomas

Maryam Saeed, Mamta Swaroop, Franz S. Yanagawa, Anita Buono

Chapter 9 **Patient Safety Issues in Pathology: From Mislabeled Specimens**

Chapter 10 **Avoiding Fire in the Operating Suite: An Intersection of Prevention and Common Sense 161**

**with Analysis 125**

**VI** Contents

J. Papadimos

**to Interpretation Errors 141**

and Stanislaw P. Stawicki

Modern healthcare continues to evolve. With the shift away from primarily quantitative meas‐ ures of performance, the new landscape of quality and value-based metrics became the hall‐ mark of the ongoing paradigm shift. *The Vignettes in Patient Safety* book series is an attempt to highlight some of the prevailing healthcare trends, focusing on highlighting the increasingly complex matrix of multidisciplinary teams, rapidly evolving treatments, technological ad‐ vancements, regulatory requirements, and ever greater patient (consumer) expectations.

The third volume of *The Vignettes* is the most successful tome in the current series. This is both a testament to the importance of the topic and a reflection of the high quality of work published in the earlier volumes. The favorable response of our readership also corroborates the growing importance of patient safety as an essential component of the modern health‐ care landscape. In fact, the permanency of the "quality and safety" mindset is slowly becom‐ ing the long-sought reality throughout our clinics, hospitals, and operating rooms.

Despite many important advances in our collective understanding of patient safety, a tre‐ mendous amount of work remains before the ultimate goal of "zero incidence" is achieved across the entire spectrum of the so-called "never events" that continue to affect our health‐ care systems. Topics discussed in the current book include fundamental principles of the performance improvement process, the application of levels of scientific evidence in clinical‐ ly relevant contexts, assessment of patient safety culture in a primary care setting, patient safety education, and a number of different patient safety scenarios.

It is our goal as editors of *The Vignettes in Patient Safety* to introduce new concepts and clini‐ cal scenarios that will enrich the cumulative value of the entire book series. Volume 3 fol‐ lows this important principle as well, adding important information regarding teamwork and communication, the "Swiss cheese" model of medical error genesis, transfusion-related patient safety issues, errors involving pathology labeling and reporting, operating room fires, and various dangers associated with intrahospital patient transfers.

The editors of *Vignettes in Patient Safety* would like to thank all of the individuals involved in bringing this important work to fruition. We also want to thank our friends and family who supported our efforts for their patience and understanding during the entire process of book preparation, editing, and readying the content for publication. In addition, we formally ac‐ knowledge and express our appreciation to all of the authors that have committed their val‐ uable time and effort to making this third tome of *The Vignettes* a success. Their contributions, especially in the context of an open source publication model in which the authors support the expenses of a publication, clearly reflect their dedication to the primary objectives of this text—and the passion to share and promote this work's important mes‐ sage. Finally, we must recognize the important role of various departments and institutions

that directly or indirectly contributed to this publication, both through their support of fac‐ ulty time and effort, and through generous contributions to the open access publication process.

As we embark on planning the next volume of *The Vignettes in Patient Safety*, we hope that the content of the first three tomes of this cycle will provide our readers with an important and actionable foundation for better understanding of key patient safety concepts (and their clinical application). We also hope that members of our audience may consider contributing novel, high-quality content to this and other projects in the area of patient safety. After all, sharing one's knowledge and experiences, with the goal of helping others and making a dif‐ ference, constitutes the highest form of giving.

**Stanislaw P. Stawicki**

**Chapter 1**

**Provisional chapter**

**Introductory Chapter: Medical Error and Associated**

**Introductory Chapter: Medical Error and Associated** 

**and Coordination**

**and Coordination**

Michael S. Firstenberg

Michael S. Firstenberg

**1. Introduction**

tions (**Figure 1**).

Alyssa Green, Stanislaw P. Stawicki and

Alyssa Green, Stanislaw P. Stawicki and

http://dx.doi.org/10.5772/intechopen.78014

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

"zero error" performance across modern health systems [3].

**Harm - The The Critical Role of Team Communication**

**Harm - The The Critical Role of Team Communication** 

Healthcare safety is among the most important considerations when designing, building, and managing modern patient care facilities and systems. Among many reasons why healthcare systems have not inherently "evolved into safety" were the combination of provider individualism and the lack of early recognition of the importance of effective communication and coordination as the primary method of ensuring maintenance of safety standards throughout the entire patient care continuum [1]. The first two volumes of the *Vignettes in Patient Safety* focus on the development of patient safety champions [2] and the continued quest toward

As our clinics, hospitals, and more recently growing networks of facilities began to aggregate providers from diverse disciplines and training backgrounds, the need for better coordination and communication to ensure safe and seamless patient care became apparent [3, 4]. Growing teams of highly trained individuals who work together, yet may not know each other, became the reality of healthcare systems that require the performance of multistep tasks of great complexity [5, 6]. In this introductory chapter, we will discuss how team communication and appropriate coordination of care are instrumental to ensuring and improving patient safety, as well as to the overall functioning of the patient safety matrix across healthcare organiza-

The Institute of Medicine (IOM) defined six key measures to improve the overall quality of our healthcare system, including safety, effectiveness, timeliness, efficiency, equity, and focus on the patient [7]. The concept of patient safety has been an active area of opportunity for

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.78014

St. Luke's University Health Network Department of Research and Innovation Bethlehem, PA, USA

**Michael S. Firstenberg** Northeast Ohio Medical University, USA

#### **Introductory Chapter: Medical Error and Associated Harm - The The Critical Role of Team Communication and Coordination Introductory Chapter: Medical Error and Associated Harm - The The Critical Role of Team Communication and Coordination**

DOI: 10.5772/intechopen.78014

Alyssa Green, Stanislaw P. Stawicki and Michael S. Firstenberg Alyssa Green, Stanislaw P. Stawicki and Michael S. Firstenberg

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.78014

#### **1. Introduction**

that directly or indirectly contributed to this publication, both through their support of fac‐ ulty time and effort, and through generous contributions to the open access publication

As we embark on planning the next volume of *The Vignettes in Patient Safety*, we hope that the content of the first three tomes of this cycle will provide our readers with an important and actionable foundation for better understanding of key patient safety concepts (and their clinical application). We also hope that members of our audience may consider contributing novel, high-quality content to this and other projects in the area of patient safety. After all, sharing one's knowledge and experiences, with the goal of helping others and making a dif‐

**Stanislaw P. Stawicki**

Bethlehem, PA, USA **Michael S. Firstenberg**

St. Luke's University Health Network Department of Research and Innovation

Northeast Ohio Medical University, USA

process.

VIII Preface

ference, constitutes the highest form of giving.

Healthcare safety is among the most important considerations when designing, building, and managing modern patient care facilities and systems. Among many reasons why healthcare systems have not inherently "evolved into safety" were the combination of provider individualism and the lack of early recognition of the importance of effective communication and coordination as the primary method of ensuring maintenance of safety standards throughout the entire patient care continuum [1]. The first two volumes of the *Vignettes in Patient Safety* focus on the development of patient safety champions [2] and the continued quest toward "zero error" performance across modern health systems [3].

As our clinics, hospitals, and more recently growing networks of facilities began to aggregate providers from diverse disciplines and training backgrounds, the need for better coordination and communication to ensure safe and seamless patient care became apparent [3, 4]. Growing teams of highly trained individuals who work together, yet may not know each other, became the reality of healthcare systems that require the performance of multistep tasks of great complexity [5, 6]. In this introductory chapter, we will discuss how team communication and appropriate coordination of care are instrumental to ensuring and improving patient safety, as well as to the overall functioning of the patient safety matrix across healthcare organizations (**Figure 1**).

The Institute of Medicine (IOM) defined six key measures to improve the overall quality of our healthcare system, including safety, effectiveness, timeliness, efficiency, equity, and focus on the patient [7]. The concept of patient safety has been an active area of opportunity for

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**Figure 1.** Idealized diagram summarizing key components of patient safety matrix in health care. Only selected components are listed, emphasizing the importance of good leadership, communication, and team coordination, in addition to other domains previously discussed in the *Vignettes in Patient Safety*.

hospitals [8] and clinicians, especially with the advent of objective scorecards and pay-forperformance measures [3, 7]. Patient safety began to transform into its current, more structured format in the early 1990s as it became increasingly apparent that hospitals were not as safe as previously thought and patients undergoing treatment at our healthcare facilities were shown to be at substantial risk of adverse events [4, 9]. The field of healthcare quality and safety encompasses numerous factors, most of which have been discussed in previous volumes of this series, including topics like leadership and organizational culture [3]. In this volume we will explore in greater detail key patient safety concepts in the context of team communication and coordination. It is only through appropriately coordinated work as a team, using proven communication techniques, that we can bring tangible benefits to new and existing healthcare platforms, making care delivery safer, and establishing greater trust in the current system [10–13]. Our exploration will emphasize the importance of teamwork in achieving the goals of the IOM and ultimately creating a universal and standardized environment and a culture safety (**Figure 2**).

with inadequate team communication and/or coordination, highlighting the critical nature of "teamwork" as opposed to the more traditional and flawed "individual blame" culture [4, 5, 21, 22]. Patient safety literature also indicates that teamwork is key to establishing and maintaining patient safety, and issues related to lack of collaborative approaches and/or communication often contribute to poor quality and safety record [21, 23, 24]. Support for constructive and collaborative thinking must permeate all levels of the organization [3, 4]. At the same time, we must recognize that effective teamwork and collaboration are not going to be inherently easy within a dynamic, complex, and unpredictable environment of modern healthcare systems. However, the above limitation should not serve as a perpetual excuse for failing to improve the current status quo, as proven by other high performance or high-stakes industries that have

Introductory Chapter: Medical Error and Associated Harm: The Critical Role of Team…

http://dx.doi.org/10.5772/intechopen.78014

3

Throughout the *Vignettes in Patient Safety* series, we continually emphasize the importance of teams, communication, and the presence of dedicated champions critical to promoting a culture of safety throughout our institutions. In an attempt to present the reader with practical information and actionable knowledge, we also focus on clinically relevant elements of implementing effective team approach including strong leadership and communication and describing key aspects of a robust organizational culture of safety. This volume of *The Vignettes* will be specifically devoted to the importance of team communication and coordina-

successfully adopted effective quality, safety, and reliability models [4, 25, 26].

**Figure 2.** Key components necessary for the creation of institutional culture of safety.

tion as inextricable elements of a safe and efficient modern healthcare environment.

Historically, the practice of medicine has revolved around a personal interaction between the patient and his or her healthcare provider [14]. This viewpoint has permeated the cultural and organizational perceptions within medicine, thus heavily influencing and shaping the delivery (and effectiveness) of care [15, 16]. Even with the changing institutional and work dynamics within the healthcare system, this individualistic paradigm continued to prevail, with physicians treating patients at the point of care, characterized by only limited collaboration and coordination with other healthcare professionals [17, 18]. The transition from a physician-centered system to a more patient-centered system required a paradigm shift that inherently led to increased care complexity and the need for better coordination and communication across multidisciplinary teams [7, 19, 20]. There is ample evidence linking adverse healthcare events Introductory Chapter: Medical Error and Associated Harm: The Critical Role of Team… http://dx.doi.org/10.5772/intechopen.78014 3

**Figure 2.** Key components necessary for the creation of institutional culture of safety.

hospitals [8] and clinicians, especially with the advent of objective scorecards and pay-forperformance measures [3, 7]. Patient safety began to transform into its current, more structured format in the early 1990s as it became increasingly apparent that hospitals were not as safe as previously thought and patients undergoing treatment at our healthcare facilities were shown to be at substantial risk of adverse events [4, 9]. The field of healthcare quality and safety encompasses numerous factors, most of which have been discussed in previous volumes of this series, including topics like leadership and organizational culture [3]. In this volume we will explore in greater detail key patient safety concepts in the context of team communication and coordination. It is only through appropriately coordinated work as a team, using proven communication techniques, that we can bring tangible benefits to new and existing healthcare platforms, making care delivery safer, and establishing greater trust in the current system [10–13]. Our exploration will emphasize the importance of teamwork in achieving the goals of the IOM and ultimately creating a universal and standardized environ-

**Figure 1.** Idealized diagram summarizing key components of patient safety matrix in health care. Only selected components are listed, emphasizing the importance of good leadership, communication, and team coordination, in

addition to other domains previously discussed in the *Vignettes in Patient Safety*.

Historically, the practice of medicine has revolved around a personal interaction between the patient and his or her healthcare provider [14]. This viewpoint has permeated the cultural and organizational perceptions within medicine, thus heavily influencing and shaping the delivery (and effectiveness) of care [15, 16]. Even with the changing institutional and work dynamics within the healthcare system, this individualistic paradigm continued to prevail, with physicians treating patients at the point of care, characterized by only limited collaboration and coordination with other healthcare professionals [17, 18]. The transition from a physician-centered system to a more patient-centered system required a paradigm shift that inherently led to increased care complexity and the need for better coordination and communication across multidisciplinary teams [7, 19, 20]. There is ample evidence linking adverse healthcare events

ment and a culture safety (**Figure 2**).

2 Vignettes in Patient Safety - Volume 3

with inadequate team communication and/or coordination, highlighting the critical nature of "teamwork" as opposed to the more traditional and flawed "individual blame" culture [4, 5, 21, 22]. Patient safety literature also indicates that teamwork is key to establishing and maintaining patient safety, and issues related to lack of collaborative approaches and/or communication often contribute to poor quality and safety record [21, 23, 24]. Support for constructive and collaborative thinking must permeate all levels of the organization [3, 4]. At the same time, we must recognize that effective teamwork and collaboration are not going to be inherently easy within a dynamic, complex, and unpredictable environment of modern healthcare systems. However, the above limitation should not serve as a perpetual excuse for failing to improve the current status quo, as proven by other high performance or high-stakes industries that have successfully adopted effective quality, safety, and reliability models [4, 25, 26].

Throughout the *Vignettes in Patient Safety* series, we continually emphasize the importance of teams, communication, and the presence of dedicated champions critical to promoting a culture of safety throughout our institutions. In an attempt to present the reader with practical information and actionable knowledge, we also focus on clinically relevant elements of implementing effective team approach including strong leadership and communication and describing key aspects of a robust organizational culture of safety. This volume of *The Vignettes* will be specifically devoted to the importance of team communication and coordination as inextricable elements of a safe and efficient modern healthcare environment.

#### **2. Patient safety and teamwork**

Patient safety can be defined as a discipline or characteristic of a healthcare system that focuses on the application of safety science methodologies to minimize the incidence and impact of adverse events, with the ultimate goal of creating a trustworthy and highly reliable healthcare delivery environment [9]. The critical importance of patient safety has been well established across the full spectrum of modern healthcare settings, including the more recent introduction of patient-centered care and quality-based reimbursement paradigms [3, 27, 28]. As the care delivery paradigm continues to evolve, we must strive to learn, grow, and make sustained improvements across all domains of practice, from the most mundane to the most complex ones. Because the focus on patient safety has its genesis in the combined desire and duty to "do the right thing" in conjunction with the realization that there is an unacceptably high prevalence of avoidable adverse events, we must all join forces and make the effort to meaningfully contribute at the personal, team, and institutional levels [3, 29, 30].

It seems that coordination and collaboration should be occurring intuitively in a high-performing medical system. However, breakdowns in communication, an essential element in care coordination, were found by The Joint Commission to contribute to 70% of adverse events [32], with a large proportion of these events resulting in mortality [38]. Teamwork is paramount not only to the development of a safe patient environment but also to improved patient outcomes, enhanced quality of care, and greater provider satisfaction [32, 38]. Inefficient team structure and poor functioning have been implicated in inferior quality of care and worse safety performance [21]. Given the complexities of modern healthcare environment, including the diversity of roles and increasing degree of specialization within essentially every area of practice/expertise, the above considerations become even more urgent [39, 40]. Consequently, the concurrent presence of well-choreographed coordination, communication, and teamwork is no longer optional in the interprofessional environment of modern health care, at all levels of every organization [40].

Introductory Chapter: Medical Error and Associated Harm: The Critical Role of Team…

http://dx.doi.org/10.5772/intechopen.78014

5

**3. Effective team communication and coordination: "Together** 

When people work together toward a common goal, remarkable achievements are possible. There are, however, important team-specific considerations. With the growth of team size and complexity, so does the potential for errors. Essential to reducing the number of errors is the presence of robust, often redundant feedback mechanisms [4, 41, 42]. In addition to improving safety and effectiveness of teams, properly structured teamwork may also help improve staff well-being and morale [21]. Consequently, targeted restructuring of microsystems and processes toward a more team-based approach can bring about important benefits and synergies [21]. Finally, thoughtful implementation of interventions that foster shared decision-making, planning, and problem-

solving can also be effective in improving both clinical outcomes and patient safety [32].

**4. Barriers to communication, collaboration, and care coordination**

Without effective communication between care providers, healthcare teams, and their patients, considerations given to safety measures are more likely to be insufficient, often

Although healthcare professionals tend to be aware of the importance of teamwork, communication, and coordination, this awareness does not universally translate into appropriate or optimal behavioral manifestations [21]. As a result, breakdowns in teamwork—rather than lack of knowledge or clinical skills—continue to contribute to a significant proportion of adverse healthcare events [21]. Thus, the importance of working effectively within a complex team-based environment cannot be overstated, with evidence from one observational study conducted in the pediatric surgical setting demonstrating that "…effective teamwork was associated with fewer minor problems per operation, higher intraoperative performance and shorter operating times" [21]. If coordinated teamwork and communication are so important to ensuring patient safety, what are some of the more common failure modes and more impor-

**Everyone Achieves More"**

tantly the associated barriers?

For any meaningful change in practice (and thus organizational culture) to occur, a shift in mindset must be embraced at both individual and institutional levels [31]. In the past, there was a widely held belief that "well-trained and conscientious" providers generally do not commit errors and that most errors occurred because of "carelessness and incompetence" [9, 32]. Consequently, punitive approaches to error identification and correction prevailed, creating an environment of "fear, secrecy, and nondisclosure" [4, 9]. The resultant "culture of blame" gradually gave way to a more in-depth understanding of medical errors, with increasing realization that only a minority of errors are clearly attributable to a single individual or factor [3–5].

Research into human factors provides evidence that in great majority of cases it is not "the individual" who is to be blamed, but rather the error results from imperfections within the organization's systems, training, equipment, and/or management [9, 33, 34]. This sparked a transition toward system-based thinking and adoption of error management, an effective method used in aviation, into health care as a way of introducing a more sustainable paradigm change [3, 4, 35]. Subsequent identification and improved understanding of various "failure modes" such as "latent failures" that may be "hidden" within an otherwise highly efficient and safe environment [35] gave us further insight into phenomena "we did not know that we did not know." Among various areas of scrutiny, it became apparent that the largest number of opportunities for improvement resided within the general domains of "team communication" and "team coordination" [36, 37].

For the purposes of our discussion, a team is described as one or more individuals working together toward a specific, shared aim [21]. This highlights the importance of any verbal or written communication between providers and caretakers where at least two individuals are involved, regardless of how trivial such communication may seem at the time. Also, integral to the team context, each individual has a special role to play within their own area of knowledge and expertise [21]. Inherent to effective teamwork, individuals should be willing to share their resources, communicate and coordinate closely in order to provide the very best care and experience for the patient from every conceivable standpoint, including clinical outcomes, quality, and safety [21]. Of note, the above statements describe nearly every team-based microsystem within the modern healthcare construct.

It seems that coordination and collaboration should be occurring intuitively in a high-performing medical system. However, breakdowns in communication, an essential element in care coordination, were found by The Joint Commission to contribute to 70% of adverse events [32], with a large proportion of these events resulting in mortality [38]. Teamwork is paramount not only to the development of a safe patient environment but also to improved patient outcomes, enhanced quality of care, and greater provider satisfaction [32, 38]. Inefficient team structure and poor functioning have been implicated in inferior quality of care and worse safety performance [21]. Given the complexities of modern healthcare environment, including the diversity of roles and increasing degree of specialization within essentially every area of practice/expertise, the above considerations become even more urgent [39, 40]. Consequently, the concurrent presence of well-choreographed coordination, communication, and teamwork is no longer optional in the interprofessional environment of modern health care, at all levels of every organization [40].
