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While hospitals nationwide log more than a 250,000 injuries a year, a small but growing number are proving that injuries are not inevitable. With a program of thorough accident review and prevention, they are experiencing dramatic declines in reported injuries. For example, St. Rose Hospital in Hayward, CA, is moving toward a "zero accident culture." That may sound impossible, but consider this: In the past year, the hospital reduced its injuries by 35%, including a decline of 38% in back strains and sprains, the most common injury among hospital workers. In the last two months of 2000, the hospital had no reported needlestick injuries.
"We’ve taken the initial two steps of educating staff and adopting the process [of safety review] to get there," says Bryan Daylor, MHROD, vice president of support services. "The next step will be adopting that [zero accident concept] as our culture and philosophy and looking at all accidents as preventable."
After an injury, Daylor asks the typical question: How could this have been prevented? The difference is in the answer he is willing to accept. Too often, harried supervisors simply fill out the form by saying, "Counsel employee to be more careful." Or they may suggest more safety education. Yet Daylor and his accident review team act like sleuths on the trail of the "root cause" of the accident, interviewing employees and supervisors and visiting work sites to find out how it could have been prevented.
"It’s changing the mindset about how you look at injuries and the follow-up," explains Janet Abernathy, RN, senior consultant for accident prevention at Royal & SunAlliance in Walnut Creek, CA, who helped Daylor establish his prevention program. "I think most people look at accident investigation as a necessary piece of documentation. They don’t take it to the next step and use it to prevent injury." (See Royal & SunAlliance’s injury review process report, below.)
When St. Rose began its program of accident review, the CEO sent a letter to all employees encouraging them to participate. That was a way of pointing out its importance, says Daylor. An accident review team investigates every lost-time injury, needlestick, or injury of an employee who sustained a separate injury within the past year. The hospital’s employee health nurse also makes note of trends — such as more than one similar accident in the same department.
This method of review relies more on the individual circumstances of an injury than annual or even monthly trends. After all, behind one injury may be a dozen or more near misses, notes Abernathy. "If you’re looking at it from an injury prevention standpoint, if you know you had seven patient handling injuries last month, how do you know where to target your interventions? The raw data don’t tell you anything."
The process begins with interviews of the injured worker and the supervisor. Throughout, the team must emphasize that the review is not punitive, but fact-finding, Abernathy notes. "When it first gets started, people are scared to death," she says. "You have to start out by letting them know this is absolutely not a fault-finding mission."
Instead of just accepting a simple statement of what happened, the review team asks questions as they seek to discover the primary cause and contributing causes. (Abernathy uses an analysis with codes for possible causes, but notes that the process can be more informal. To obtain more information on causation trend analysis, see editor’s note at the end of this article.) For example, at St. Rose Hospital, a nurse who "floated" from the intensive care unit to the fourth floor suffered a shoulder injury when transferring a patient for surgery. The simple reason: She failed to use a mechanical lift.
But when Daylor’s team investigated, they found the unit didn’t have enough lifts readily available, "floating" staff weren’t always aware of where the equipment was located, and the policies on using lifts weren’t enforced strongly enough. As part of the solution, the hospital is buying more lifts. Orientation of floating nurses also will emphasize the location of safety equipment, he says.
Solutions to safety problems can be stunningly simple — or too complex to fix immediately. At Radiological Associates of Sacramento (CA) Medical Group, which has almost 700 employees at 23 sites, an employee was walking down the hall when someone opened a door and bashed her. "You would think it was just something that occurred, that she was in the wrong place at the wrong time," says Judee Zimmerman, senior human resources analyst.
Instead, the medical group looked for preventive action. "We changed the way the door swung so the door went the other way, so it couldn’t have happened," she says. However, they found it more difficult to prevent needlesticks after needle biopsies of breast cysts. The fluid within the needle is sent to a lab, and nurses have been recapping needles after the procedure. "We did some retraining on needle recapping [while] we’re continuing to search for an alternative," she says.
The accident review process alerted safety officials of the recapping problem, says Zimmerman. "We had no clue prior to that [review]," she says. "None of that was documented in the injury reporting process. We would have just treated her, counseled her to be more careful, and moved on."
The accident review process alerted St. Rose Hospital to safety devices that actually contributed to a temporary increase in needlesticks. The hospital implemented new training and sought alternatives to some devices, Daylor says.
The most important aspect of accident investigation is incessantly asking the question, "Why?" says Abernathy. She recalls one instance of a hospital employee who slipped on the stairs and suffered a head injury: "Why did she slip?" asked Abernathy. Her shoes were slippery. "Why were her shoes slippery?" she followed up. The employee had just stepped in a puddle. After continually asking questions, Abernathy discovered that a kitchen employee had used the wrong container to dispose of used oil, and had carried it, sloshing, across the floor. No one had bothered to clean the oil.
Sometimes, accident review involves role-playing — asking the employee to simulate the conditions of the accident. That led Daylor and his colleagues to discover that the handles on the linen carts created awkward body mechanics for someone shorter than average. Since the handles couldn’t be adjusted, the team decided to instruct employees to empty the carts before they were completely filled, thus creating a lighter load.
"It’s a matter of tolerance and acceptance," says Daylor. "If you just want to accept what’s written on a report and base your [prevention] decision on that, you’re going to miss something. When you walk [employees] through it, sometimes you get a different picture."
The ultimate goal is to review near misses as well as accidents, so accidents can be prevented before they happen. "The only way [safety] stays a priority is being consistent and persistent in responding," says Daylor. "It’s really a matter of valuing your employees. It may sound cliché, but they are your most valuable resource."
(Editor’s note: For more information on causation trend analysis, contact Janet Abernathy at Janet_Abernathy@rsausa.com.)