Focusing on Patient Care Solutions

Program Director, Dr. Townsley Discusses the Importance of Problem Solving

At first glance the similarities between the following two tragedies are not readily apparent. The first incident transpired at Tenerife Airfield on March 27, 1977 and resulted in the deaths of 583 passengers on two colliding Boeing 747s. The accident was caused by KLM flight 4805 commanded by a pilot who was ironically the Corporate Vice President and Director of Safety for the airline with more than 30 years of experience as a pilot.

The second incident occurred at Johns Hopkins Hospital, arguably one of the world´s finest health care facilities. In this case, a young post-surgical patient died while under the care of an expert team of physicians and nurses. In each of these scenarios, despite the supervision of experts, a cascade of errors ensued that culminated in disaster.

Interestingly, the three primary causes of both events are similar; miscommunication, authoritarian culture, and unchallenged assumptions. While I will leave it to you to read the well documented events of the Tenerife accident (Google, Wikipedia), the sequence of events at Johns Hopkins are as follows. During morning rounds, the surgicalist team rounded on a 4-year-old post-surgical patient who appeared to be doing well. However, as the morning progressed her condition deteriorated. Despite multiple calls from the experienced nurse who was caring directly for the patient, the surgical residents on service insisted they had just seen the patient and she was fine. By the time the surgical team reacted to the nurse’s admonitions, their patient had died of dehydration- an inconceivable and preventable event in a modern hospital.

Fortunately, Johns Hopkins and the patient´s family capitalized on this horrific incident to productively strategize how to prevent this type of error from happening again. They re-evaluated their Business and Quality Policy, "every system we use is perfectly designed to achieve the results it gets," and accepted that until they admit their doctors make mistakes they will never design a system to catch those very mishaps. Thus, they re-designed the system and identified three principles of safe design; standardize, create checklists, and learn when things go wrong.

Furthermore, Johns Hopkins now teaches that teams (of nurses, doctors, pharmacists, respiratory therapists, etc.) make wise decisions when there is diverse and independent input. Health care is a ´team sport´, the ICU team rounds on patients in an atmosphere of openness where anyone can challenge assumptions about the patient’s care. All voices are heard.

Apogee has always encouraged thinking outside the box and focusing on solutions rather than problems. Accordingly, at our program in Pendleton, we decided to institute a similar team-approach in the ICU of our small critical access hospital by rounding with doctors, nurses, pharmacists, medical students, respiratory therapists and occasionally other support personnel. At first, it was slow going and we had a few false starts. The protocol for speaking up took some getting used to but the results were almost immediate. We began catching more ventilator and medication errors, lines (Foley & central catheters) and medications were removed in a more timely fashion, and fewer phone calls were made during the day to the physicians.

The group that surprised us the most was the families of the critically ill patients. Since all staff knew the plan of care, these families were confident we truly were doing everything possible for the patient, even in situations where the patient passed away.

I don´t know what the future holds for our program but inspired by what is printed on the back of our business cards, "What´s best for the patient is best for the practice," I think this is a definite step in the right direction and we are not going back.

Malcolm Townsley, MD, PhD
Program Director
Pendleton, OR