Regulating Safety in the Outpatient Wound Clinic

As the proverbial phrase begins, “To err is human.” However, in the era of patient-centered care that we currently live (and work) in, where the concept of patient safety is seen through a “zero harm” lens, achieving divine forgiveness in the face of medical errors is not likely to come from any patient, administrator, or payer. Of course, the real challenge for any healthcare provider is improving patient safety when accounting for existing barriers, such as being able to provide individualized evidence-based care when an increasing amount of time is being spent on the phone with insurance company representatives in an attempt to get approval of needed products and/or interventions. 

The well-known axiom by Benjamin Franklin, “An ounce of prevention is worth a pound of cure,” would be tough to debate. But how do we apply this premise to our daily practice when rendering treatment to our patients? I’ve always told others that I learn from my mistakes, but generally do not make the same mistake twice. And while it is the “early bird that gets the worm,” it is often the “second rat that gets the cheese.” For us humans, we need to know how to address harmful versus non-harmful mistakes. We also need to ask ourselves if there truly is a difference between the two. To illustrate this point, I’m embarrassed to tell you about a recent occurrence that suggests there isn’t much of a distinction at all. First, I’d like the record to show that I have been climbing ladders for years. (And, yes, you may somewhat know where this is going.) Looking back, there have been minor and non-injurious “accidents” that have occurred involving ladders. This winter, I sustained an injury outside of the healthcare setting that had the potential to change my life after I fell from a roof when my ladder shifted beneath my feet. As I recall the incident today, it all happened so fast — as it always seems to do when any accident occurs. However, in this case, I can honestly say that my inability to learn from the past led to a fairly serious injury during a rather routine task. (I was cleaning the gutters.) Working without a ladder harness, an unsafe practice that had led to near-misses for me previously, resulted in an adverse event that could have been fatal. While I’m currently on the mend and did not miss any work, it is certainly fair to see that my prior “non-harmful” mistakes (ie, near-misses) were rather quite harmful when considering my recent accident. The truth of the matter is that my own ignorance to make a change in light of the near-misses was the true nature of the harm. 

DEFINING PATIENT SAFETY 

As defined by the National Patient Safety Foundation, patient safety is the “avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of healthcare.” National patient safety goals, including appropriately identifying patients, applying/incorporating the safe utilization of medication, preventing infection and surgical mistakes, and improving communication, have been well defined. The question becomes: How well are these guidelines being followed within your clinic and elsewhere? While achieving the answer to this question cannot be accomplished within this writing, we can review some pertinent definitions related to safety that should stimulate a review of any clinic’s protocols and measures taken to increase the likelihood of a safer practice environment existing. (Note the defining source in parenthesis.) 

Prevention of Harm: Freedom from accidental or preventable injuries produced by medical care. (Agency for Healthcare Research and Quality [AHRQ]) 

Near-Miss: An unplanned event that did not result in injury, illness, or damage – but had the potential to do so. (National Safety Council^®) 

Error: An act of commission (doing something wrong) or omission (failing to do the right thing) leading to an undesirable outcome or significant potential for such an outcome. For example, ordering a medication for a patient with a documented allergy to that medication would be an act of commission. Failing to prescribe a proven medication with major benefits for an eligible patient (eg, low-dose unfractionated heparin as venous thromboembolism prophylaxis for a patient after hip-replacement surgery) would represent an error of omission. (AHRQ) 

Medical Error: The failure of a planned action to be completed as intended (ie, error of execution) or the use of a wrong plan to achieve an aim (ie, error of planning). (Institute of Medicine) 

Adverse Event: An injury caused by medical management rather than the underlying condition of the patient. (Harvard Medical Practice Study) 

Preventable Adverse Event: One that occurred due to error or failure to apply an accepted strategy for prevention. (AHRQ) 

Ameliorable Adverse Event: An event that, while not preventable, could have been less harmful if care had been different. (AHRQ) 

Adverse Event Due to Negligence: Something that occurred due to care that falls below the standards expected of clinicians in the community. (AHRQ) 

Wound care clinicians and program directors may also be familiar with the phrase “history repeating itself,” which indicates that if you want to improve the future you must be cautious to not repeat any poor decisions from the past. If we are observant in our daily clinic operations and recognize deviations from standard of care, we may prevent future problems or errors. Consider a patient who’s living with diabetes and chronic venous insufficiency who has been compressed without an arterial study and no injury has been experienced. Well, a crisis may have been avoided for what should be considered a near-miss here — as this example had the potential to create a negative outcome. This scenario may happen around the country more than we would think, and typically staff members are not inclined to question an ordering physician because the instinct tends to be to follow orders. So, be mindful of this if you are in the position of writing orders. If your facility has policies and procedures in place regarding the establishment of adequate circulation and compression, be sure to follow them (and initiate a conversation if there is no such policy/procedure). Even in instances in which a staff member does recognize that a policy is not being followed, I don’t know many people who will take the initiative to have a meaningful communication with the physician. So where is the patient advocate in this situation? While this hypothetical example absolutely calls for any staff member to speak up, it is on the ordering physician to first ensure that he or she is effectively following safe protocols. 

SAFETY & COMMUNICATION 

For those clinic program directors who nurture a culture of safety with their staff members while encouraging communication, patient safety will definitely improve. Case in point: recently, I did not agree with a physician on how to proceed with a specific intervention due to objective findings in an attempt to prevent a possible adverse event. This was not your typical wounded patient whose condition was complicated by a multitude of comorbidities. A joint plan for the patient was established with the physician and the healthcare team that utilized available resources while following policies before proceeding with a comprehensive treatment. I’m proud to say today that a near-miss, medical error, and adverse event were avoided. Of course, this example proves that the first step to solving or preventing future problems is to recognize the potential for a problem before it exists. The second step is to collect timely data to determine possible risk factors and to address those risks promptly to prevent potential future occurrences. Ongoing, consistent culture of safety should be promoted.

That said, it must be acknowledged that, often, wound care clinicians will encounter complications when providing care due to the multiple comorbid conditions that many patients present — which in and of itself creates an “unsafe” situation. However, when the goal is to prevent adverse events, we all need to assume this great responsibility despite the challenges we often face at the time of initial presentation. Charles Perrow, PhD, an emeritus professor of sociology at Yale University, has estimated that in any industry, 60-80% of accidents, on average, will involve human error. This still raises the question of whether human error is ever connected to the failure of the overall system in place to prevent errors. In some cases, it certainly will be a combination of both factors. According to a 2012 report by the Office of Inspector General, hospital incident-reporting systems captured only an estimated 14% of the patient “harm events” experienced by Medicare beneficiaries.1 Hospitals investigated those reported events that they considered most likely to lead to quality and safety improvements and made few policy or practice changes as a result of reported events, the report claims.

Hospital administrators classified the remaining events [86%] as either events that staff “did not perceive as reportable” [61%] or as events that staff commonly report, but “did not report in this case” [25%].1 Wound care clinics will typically develop policies and procedures to reinforce expected standards while guiding employees in what is acceptable and unacceptable behavior. Policies and procedures are essential to a clinic, as they provide a road map and promote safe practices. Additionally, once an injury is sustained, it is imperative to collect the relevant data and follow all reporting policies to avoid future occurrences. Accurate data is needed to make appropriate adjustments, however. The employer and the employee share a responsibility to keep our clinics safe. In other words, we all must be willing to report incidents and system failures in order to accomplish true evidence-based treatment. 

Frank Aviles Jr. is wound care service line director at Natchitoches (LA) Regional Medical Center (NRMC); wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapy (PT)/wound care consultant at Louisiana Extended Care Hospital, Natchitoches; and PT/wound care consultant at Cane River Therapy Services LLC, Natchitoches. 

1. Hospital incident reporting systems do not capture most patient harm. OIG. 2012. Accessed online: https://oig.hhs.gov/oei/reports/oei-06- 09-00091.asp