Nothing Less Than Zero Harm

Safety is a key UH value

UH Clinical Update | November 2020

By Cliff Megerian, MD, President, University Hospitals

As physicians, nearly every one of us can recall a moment when everything seemed to be going well for a patient, until suddenly something went wrong – something that in retrospect could have been prevented, or could be prevented in other patients.

For Amitabh Goel, MD, the Chief Medical Officer for UH Geneva and UH Conneaut Medical Centers, a scenario like that occurred eight years ago and triggered an intense mission for “zero harm” that is unabated.

Dr. Goel had performed an operation in the underarm of a woman with a high BMI. A nurse checked on her post-surgery, and she was recovering well. About 30 minutes later, Dr. Goel happened to stop by with the same nurse and the patient was not breathing.

It was a complication connected to her reaction to the opiate medication used in the anesthesia.

“We put her on oxygen immediately,” says Dr. Goel, a surgical intensivist. “Fortunately, we saw her just after she stopped breathing. If we hadn’t, she’d have developed an anoxic brain injury and died – and she was a young woman, a nurse. It was a near miss.”

It haunted him, and that, he says, was the beginning of his journey to make ‘zero harm’ his cause. Soon after, the criteria for opiate use in high BMI patients was reconsidered, and he ensured that every single patient at UH Geneva wore a pulse oximeter that would send out an alert if their oxygen levels began dropping.

Already at that time, Dr. Goel had become aware of another surgical intensivist, Peter Pronovost, MD, PhD, then at Johns Hopkins Medical Center, whose mission also was ‘zero harm’ and who had taken the infection rate there for central line catheterizations from 11 percent to zero in one year, preventing what could have been 43 infections and eight deaths. Those results were replicated by hospitals in Michigan, where his protocol addressing catheter-related infections also made them drop to nearly zero.

Dr. Pronovost did this not only by coming up with a pre-surgery checklist that had to be followed to prevent infections, but by empowering everyone in the OR – nurses included – to speak up if something had been missed by the surgeon.

That changed everything.

Today, nurses here and elsewhere, have the authority – and the back-up from hospital leadership – to speak up.

For a long time, the hierarchical culture in the OR meant that a nurse could be fired by a surgeon for speaking up.  Many of us remember when we as doctors, right or wrong, were given absolute say in patient care, and a nurse could have lost his or her job for questioning anything.

That was an embedded practice throughout medicine. Now it is not. In fact, here at UH, if a physician ignores a warning by a colleague that something is amiss, the behavior will now be considered reckless negligence. That’s a serious charge.

But is there anything more devastating than a patient dying because of an error that could have been called out and corrected? A life – even a child’s life - cut short that didn’t have to be, by an oversight?

It was two young girls at Johns Hopkins who died from catheter-based infections that made Dr. Pronovost examine not only the practices around the use of those catheters, but the culture of hierarchy. It has saved thousands upon thousands of lives, for which he gained international acclaim. Dr. Goel could not have guessed when he first heard Dr. Pronovost at a conference that he would join UH in 2018 and become UH Chief Quality & Clinical Transformation Officer.

Practicing medicine has always been high-stakes. Necessary risks are inherent, but medical errors are not. Still, as human beings, all of us are subject to forces – especially distraction – that can contribute to an error.

Dr. Goel tells another anecdote of how, just before he began an emergency appendectomy, a nurse spoke up to say that she might have forgotten to put the footboard on the operating table. That could have led to the patient sliding downward during the surgery. “She was right, and we put the footboard up,” he says. “Now we have added that to our checklist, which is written in large letters on the board in the OR.”

Distraction has always been a factor when it comes to medical errors, and as clinicians, we all know that human beings are fallible. We might be thinking of something urgent to do with one patient while we are treating another.

And of course, we have never been under more ongoing stress than we are during this COVID-19 pandemic. We worry about our patients, our loved ones, our colleagues, and our own health. We know caregivers at UH are suffering from COVID, as are more than 1,000 caregivers at the Cleveland Clinic.

I cannot think of any time ever when we have been as stretched, and as stressed – and for so many months. For all us, our staff and colleagues – even our patients or their family members – may be our extra eyes and ears. When clinicians are distracted despite our best efforts, we rely on others to call our attention to what we might not see.

But Dr. Pronovost points out that the biggest barrier to zero harm is the narrative we tell ourselves. “Too often, we accept harm as the cost of caring for sick patients,” he says. “We only get to zero harm when clinicians start believing that these infections are preventable and that as individuals, we can do something about that.”

At UH, we can change the narrative so that all of us aim for zero harm, and believe that we can achieve it.

Many of you have undoubtedly heard the acronym we use at UH to remember all the components of what we strive for: Excellence. Diversity. Integrity. Teamwork. Compassion. Perhaps we should add an “S” at the end for “Safety.”

Patient safety means striving, always, for zero harm. This must remain at the forefront of what we do.