INSIDE LOOKING UP
A HOT AND SULTRY SUMMER NIGHT in the dog days of August, I was working the night shift as a float orderly in an urban community hospital. It was a shift that started like any other; but this one was different. This was a night that would dramatically change lives–including mine.
Let’s call him Jimmy, a child somewhere between eight and ten years old who lived in this aging blue-collar Midwest neighborhood. His mom brought him to the emergency room because his breathing had changed and she was worried. The emergency physician diagnosed Jimmy’s loud wheezing as a bad case of croup.
At this time, some thirty years ago, he would have been treated and released.
This night, however, Jimmy was admitted to the hospital and sent to 2 South; known to me as the Stroke Floor where the majority of patients were elderly with a variety of medical needs including extended rehabilitation from cerebrovascular accidents, or CVAs.
I transferred Jimmy from the emergency room gurney to his bed. The nursing supervisor had reassigned me from the emergency department to 2 South as things were busy on the floor, so I got to follow Jimmy. Within minutes of arrival, Jimmy’s breathing worsened. The house physician was paged but while he was in transit, Jimmy’s high-pitched gasps turned silent. While Jimmy struggled to find even a wisp of air, he turned from pale grey to blue and the panic in his eyes dimmed as he fell into unconsciousness. Jimmy’s struggle to breathe ceased. The clinical team snapped into action.
The overhead page blared “Code blue 2 South, Code blue 2 South, Code blue 2 South.” The team rushed to the bedside with the code cart, but now the panic was ours. The nurse scrambled for the laryngoscope and endotracheal tube that would be Jimmy’s lifeline, but despite her frantic search there was no pediatric equipment in the cart. Someone was asked to run to the surgical floor for the equipment, but it was too late, Jimmy’s heart stopped beating. Despite numerous attempts, an airway could not be secured. Forced positive pressure leaked outside the bag and mask as the respiratory therapist labored to deliver lifesaving air and oxygen, filling the room with an unsettling honking noise I had never heard before.
It seemed to last forever. But after ten or fifteen minutes passed, the code was called. Jimmy was pronounced dead.
I don’t remember much from there. I remember crying by myself in a completely dark, empty waiting room abandoned in the still of the night. I remember the medical team crying as well and not being able to look each other in the eye. The family came and joined Jimmy’s mom. A priest came. They left. Somehow the clinical team carried on that night.
I remember the next evening when I crawled back to work. I was asked not to speak about the prior evening, what had happened, what hadn’t happened. Rumor thrived in this silent space. I heard that the parents were told that Jimmy had died of natural causes due to a serious condition called epiglottitis and that he could not be saved. No mention of the problems I had witnessed. I never heard anything more and as I was told, I said nothing more. Soon talk of that night faded away. Yet, over the coming weeks and months, then years—I promised myself I would do whatever I could to make sure this could never happen again.
I became a pediatric respiratory therapist working in one of the nation’s best pediatric hospitals. Yet, all of my training did not prepare me for what then was not addressed in clinical training: medical error—its causes, its scope, its prevention. Its crushing impact on patients, families, and providers. I became a patient representative and then a risk manager, only to witness an endless repeating pattern of lives lost to preventable medical error that should not have been.
This isn’t to say some progress hasn’t been made in the last thirty years in keeping patients safe as they move through medical systems. Individuals and institutions around the world have devoted themselves to changing healthcare for the better, and as a result, we have made some miraculous strides in our medicines, our technologies, and our practices. But our progress to date towards keeping patients safe from medical harm falls woefully short of perfection, or even really, good enough. To say otherwise is an injustice; too many lives are slipping away due to preventable medical error.
A 2013 review from the Journal of Patient Safety estimates that in the United States alone, between 210,000 and 400,000 patients each year that go to the hospital for care suffer some type of preventable harm that contributes to their death.¹ This means that even if we were to take the lower threshold of this estimate, 575 lives will be lost unnecessarily today, tomorrow, and every day—every year. Now more than ever, clinical enterprise risk management and patient safety systems must bear the burden of that number; they must become more effective and efficient; they must seek out solutions to fully and finally eradicate medical error. Zero harm must not just be aspirational words, but the central, unequivocal, and measurable focus of risk management and patient safety work.
Some years before this study, Douglas Hubbard published his 2009 book, The Failure of Risk Management: Why it’s Broken and How to Fix It, in which he asserts that the prevailing methods of managing risk across all industries are not doing what they set out to do.² Industry executives are not paying enough attention to the outcomes of their strategies; they are failing to measure whether or not their methods are successful. In the healthcare context, the result of this is that today 575 people died that shouldn’t and the same result will occur tomorrow, and the next day, and the next.
Hubbard was right—managers of risk and safety, ourselves among them, were not and are not focused enough on measuring the effectiveness of our strategies. Inspired by Hubbard’s call to action, the risk management team at The Risk Authority Stanford set out on a new path to rethink everything we were doing. We set out to strengthen our risk analysis methods and enhance our management processes. More than this, we were inspired to develop our own evidence-based methodologies for managing risk and keeping patients at the center of our vision. Toward this end we launched Innovence™, a platform dedicated to the art and science of risk management effectiveness, and we made a commitment to focus on evidence and innovation equally with the patient at the center of our focus.
It is not enough to favor one over the other. Evidence without a defined process to escalate innovation will never move the mountains of factors driving medical error that so urgently need moving; innovation ultimately requires evidence to sustain momentum—though we mustn’t stall progress by relying solely on evidence as a catalyst to ignite the process. But there is no simple answer, and there is no one right way to approach this challenge. Rather, there are infinite possibilities for how to take action and transform the way risk and safety are managed in healthcare; our approach is simply one possibility.
As managers of risk we should be unsettled by our lack of effectiveness, and work to seriously step-up innovation with the end point of moving from 575 to zero harm in a demonstrable way. But rather than debating or dwelling on how risk methods have failed in the past, it is vital to pick ourselves up and pursue a new course of action, to see the hope and inspiration that comes with innovation and advancement, to shine light into dark places and bring them to light.
To change risk management, what are you willing to risk?
Risk management has the potential to transform the safety of healthcare; to generate actionable risk intelligence; to enable faster adaptation of targeted solutions; to mitigate loss and create value; to reduce harm and improve patient safety. The practice of risk management is rich with untapped potential, and as we mine its depths, the promise of risk management will burst to the surface—the commitment to support and protect patients and clinicians, and to offer care that doesn’t falter.
Now more than ever, it is a time for reflection and revelation; a time to reevaluate and seek answers; a time to prepare and take action. Healthcare risk management is on the brink of a new frontier. It’s time to break through the barriers that have long hampered our progress in eradicating medical error by modernizing preconceived ideas, building on traditional working approaches, and embracing the new. It’s time to look at things through a new lens, with new clarity, and new focus. It’s time to drive ourselves to be creative thinkers, to push the limit of what’s possible, to become innovators.
The biggest risk you’ll ever take is not taking the risk to innovate.
But where do we start? The world around us is evolving, and sweeping reform in healthcare, economics, and politics can create seemingly insurmountable challenges. The idea of change can be daunting when we aren’t sure where it might bring us, or how far we must travel along its winding road. But changes must be made; lives depend on it.
So we start by rethinking our positions and our priorities, reexamining our values and processes, and then reorganizing ourselves, teams, and structures. At The Risk Authority Stanford we know that the future of healthcare risk management brims with the possibility to change lives, and we are committed to doing everything in our power to help make that change happen. We are, quite literally, inside, looking up.
This book is not a guide or a checklist (though our next book will be more along these lines). Rather, it’s a beginning. It is a turning of the key in order to unlock the door for changes to be made. It’s our attempt to create a channel for discovery that opens minds to innovation and helps to carve space for creation.
It is my fervent hope that you will reach for this information-rich book over and over, and that Inside Looking Up will help to inspire new and innovative approaches to managing risk and patient safety holistically and strategically. I hope that at this twilight in healthcare, readers will use this book as a treasure trove of new ideas, and that the book will inspire you to continue mining the depths of its pages, always discovering something new. Ultimately, it’s my hope that it will spark new ideas and conversations, and that together we will redouble and escalate efforts to innovate, collect, and follow evidence that can make a difference on a significant scale.
There is no destination but the journey. There is no end point but continual improvement and perpetual renewal of our unending promise to try, perhaps to fail in the attempt, but then to try harder until we succeed—and then to do it again.
Thirty years have passed since Jimmy’s life was lost; thirty years since I first made that promise to myself. And how many countless lives have been lost since? It’s time for us all to renew the promises we’ve made to ourselves and our patients. It’s time to reawaken. It’s time to wrap the tenets of these pages around ourselves like armor and charge into the fray. It’s time to question everything, to think bigger and faster, to motivate each other, to build upon what we have to make our futures stronger and brighter. It’s time to reenergize our battle with a faceless enemy and refuse to surrender.
It’s time to lead the charge.
- James JT. A new evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-128.
- Hubbard DW. The Failure of Risk Management: Why It’s Broken and How to Fix It. Hoboken, NJ: Wiley; 2009.