Recently, The Joint Commission released its sentinel event data from 2022. The report describes 1,441 sentinel events in 2022 – a 19% increase from 2021, and a 78% increase from 2020. In January of 2023, a retrospective study of hospitals in Massachusetts was published which found that in a random sample, at least one adverse event was identified in 23.6% of admissions, and preventable adverse events occurred in 6.8% of admissions.
Reducing errors and improving patient safety have been considered a top priority since the IOM report “To Err is Human: Building a Safer Health System” was released. But that was in 1999. While some great strides have been made, it’s been almost 25 years and we are still seeing year-over-year increases in reported errors.
Is this a real problem or artifact?
Are we just doing a better job of reporting errors? Maybe. Do we just have more admissions each year, causing the number of events to look artificially higher? Possibly.
In reality, I believe the answer is more troubling. Most systems tend to be reactive in their approach to safety, rather than proactive. Additionally, people tend to focus on the most immediate dotted line to the error that occurred. But in fact, The Joint Commission’s analysis of these sentinel events found that the biggest contributor to medical errors is communication breakdowns. That statistic has not changed since 2016! In their most recent sentinel event report, The Joint Commission describes the issue with communication breakdowns as a failure to establish a “shared understanding or mental model across care team members, or no or inadequate staff-to-staff communication of critical information.”
It isn’t just forgetting to call someone, or misunderstanding something. The problem is much deeper: we are not speaking the same language. We are not working with the same understanding of what needs to get done, what has been done, or of what “done” even means.
We work as a team … or do we?
In other words, in medicine, we say we work as a team, but I would argue that in fact, we do not. Despite everyone’s best intentions, we systems and processes have us working in silos, on different schedules, and in different tech all together. As a result, we are rarely on the same page at the same time. In fact, it often feels like the left and doesn’t know what the right hand is doing. As a result, not only do we make mistakes, but we waste an inordinate amount of time trying to catch up with each other, messaging back and forth, and the data shows that we never fully understand what everyone else is doing. And patient suffer for it.
In other industries, teams face similar problems with remote and distributed work. They leverage project management software such as Monday or Trello, to make sure everyone knows what everyone on a team is doing…at any time. Nearly every industry from construction to even party planning leverages these tools. Yet healthcare, which is arguable one of the highest stakes, highest acuity industries, does not. As clinicians, we are given the EHR, a collection of static updates, or reports, that are overloaded with duplicated and difficult to read text, and told that it should do everything we need. But it simply does not. EHRs are not designed to help us deliver care effectively or to work as a team. They are designed to facilitate the business operations of health care. Now to be fair, some EHRs do dive very deep into specific workflows for particular disciplines. Despite that, they do not provide a whole person view of what everyone is doing for a given patient, or cohort of patients at a given time. As a result, care delivery teams resort to using other tools as workarounds, and these workarounds are not efficient or collaborative.
For example, I might jot a follow up task on a post-it note or on a list I printed from the EHR. If I’m called to a patient’s room to help with an urgent issue, this information travels with me in my white coat pocket. The rest of the team can’t see it, and they continue caring for the patient without the most up-to-date information. Even if I’m not pulled into something else, it’s easy to leave a sticky note on the computer or forget my printed list in a patient’s room (ask any doctor or nurse…this happens all the time!). Even if I don’t lose the note, how do I make sure the whole team sees it? In real-time? Do I send text messages to every team member, even if it’s not urgent? Do I EHR message them all, further filling their inboxes? And what if I forget to send it to one of the team members? Or one of them changes their schedule unexpectedly? Fundamentally, in order to be share anything written on paper with anyone else, that information needs to be either re-written somewhere else, or repeated verbally. This is not only a waste of time, but introduces error.
To further compound the situation, most of the things written on paper, or in email, text messages or white boards, often never make it to the chart. Because again, it would require writing that information again. That means we are either double/triple documenting, or we are losing large amounts of coded diagnoses and relevant information.
Caring beyond borders
Another challenge is collaborating with broader clinical teams in other care settings. Interoperability is getting better, but truly usable & interoperable solutions are still far from where we need them to be. If I discharge a patient to a skilled nursing facility, will the clinicians at the SNF receive the patient information before the patient is rolled into the facility? More importantly, will it come in a form that they can easily see what needs to get followed up on and what is most important not to miss? The fact is, they often don’t. A study found that information being sent from the hospital to a SNF was delayed for over half of all SNF-hospital pairs. If we want to maintain quality care for patients during their entire healthcare journey, we need to be able to quickly share actionable information with the next person caring for them, regardless of what health system they are working for, or what EHR they use.
The new alert fatigue
Interruptions impede care. As clinicians, it seems we’re constantly getting alerts – emails, phone calls, EHR notifications, you name it. Providers in the VA receive an average of over 100 alerts per day, while another study found that emergency department physicians are interrupted every six minutes. Preliminary results from a study ongoing at a large quaternary care center shows front-line acute-care clinicians getting interrupted by a message every 2.5-4 minutes across a 12 hour shift, every single weekday.
When we’re interrupted, we have to switch our attention to the alert, and then switch it back to the original task. What happens if I was reading an important CT scan result with an incidental finding of a lung mass? That interruption could lead to me getting to the bottom of the scan result, getting distracted, and missing the finding all together. Interruptions and context switching in medicine can have grave consequences.
How can we address these problems??
No tech can magically fix a complex problem like this. As with any well designed sustainable solution, it takes people, process and technology to drive true change. However, while poorly-designed technology has contributed to the problem, well-designed tech can absolutely play a role in improving it. How we practice medicine has evolved – it is time for our tech to evolve with us.
Today, clinicians work in large, multidisciplinary teams across different locations. We need platforms that make it easy for teams to collaborate on patient care – even when they can not be in the place. First, the technology should be available when and where we need it – in the EHR where I am working, or in the palm of my hands when I am not at a desk. I want to write something once, and make sure everyone who needs to see it, can. Instead of having to write the same thing 10 times. Everyone is simply too busy for that kind of distraction.
Asynchronous collaboration allows people to check on the patient’s status and what needs to be done, when they have time. This type of batching workflow reduces interruptions, improves efficiency, and reduces errors.
If I have taken the time to write out a list of what needs to be done for a patient, everyone else on the team should be able to use and build off that list without having to keep an entirely separate one. Cross site, cross team, cross EHR collaboration is essential for us to provide safe, high quality, high value care.
While healthcare has worked to improve patient safety, we still have a long way to go. Technology should be viewed as a tool that, if designed and implemented well, is seamless with workflow. It should make it easier for clinicians to care for patients, not harder.
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