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September 2005  |  Perspective
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Playing Well with Others: “Translocational Research” in Patient Safety

Perspective

 

by Robert M. Wachter, MD

Translational research is all the rage in biomedicine. In its purest form, the concept refers to the translation of basic research discoveries into clinical applications, followed by patient-oriented studies to demonstrate benefit.(1) Increasingly, it also refers to the ability to successfully steer these biomedical discoveries into and through a commercial pipeline. Many academic medical centers have established centers and institutes to create the infrastructure and break down the silos to catalyze translational work.

It strikes me that much of the progress that we have made in the patient safety field over the past decade reflects a different kind of translational research: the translation not of basic research discoveries into clinical applications, but of insights and practices from non–health care fields into health care. To highlight the movement from non-medical fields into medicine, I propose that we call this translocational research.

Here’s how translocational research works: an investigator or systems leader eyes an apparently effective practice from outside of health care and wonders whether there might be some relevance to a safety-related problem in medicine. He or she proposes a new clinical practice, involving the adaptation of the non–health care practice into the appropriate medical context. A series of studies, sometimes observational and sometimes interventional, are undertaken. If the practice proves to be successful in fixing a safety-related problem, the change may be widely adopted, sometimes promoted by a mandate (ie, a new regulation or law) or a change in professional norms (Figure).

Let’s consider a few examples. The concept of appropriate ratios of “providers” to “consumers” was not invented by nursing researchers. Rather, we are well familiar with teacher-to-student ratios, with better ratios associated with improved educational outcomes. Aiken’s pioneering observational studies demonstrating the association between higher nurse-to-patient ratios and better outcomes applied this line of reasoning to health care.(2) Her studies helped fuel a California law mandating minimum nurse staffing ratios.

The link between excessive work hours and poor performance is also well known from other industries, enforced by regulations limiting consecutive duty hours among truck drivers and airline pilots.(3) Research demonstrating that the effect of 24 hours of sustained wakefulness results in performance equivalent to a blood alcohol level of 0.1 helped lead the Accreditation Council on Graduate Medical Education (ACGME) to adopt duty hour limitations in 2003. More recently, Landrigan and colleagues demonstrated that shorter shifts among intensive care unit residents led to fewer medical errors.(4) Although the study did not find that the benefits of shorter shifts were compromised by the necessity of more “handoffs,” this concern has been raised in enough quarters that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) made improving handoffs one of its 2006 National Patient Safety Goals. Interestingly, as institutions struggle with how to improve handoffs specifically, and how to accurately transmit key information more generally, they are looking to the military (including the use of the NATO alphabet; alpha for A, bravo for B, etc.) and the take-out restaurant industry (which has long used read-backs to ensure that orders have been correctly transmitted) for guidance.(5)

A third example comes from aviation, in the form of crew resource management (CRM). In the late 1970s and early 1980s, commercial aviation began to require interdisciplinary teamwork training designed to improve communication and break down hierarchies. As the detrimental impact of poorly functioning teams on patient safety has been recognized, it has been posited that using CRM techniques might yield similar benefits. Preliminary studies have supported this hypothesis.(6) If additional studies bear this out, we can also expect pressure for CRM or other forms of teamwork training to be required (perhaps by JCAHO as a National Patient Safety Goal, or by the ACGME as a requirement of training) to grow.

The Table cites these examples and several more, including the use of simulators to improve technical and team-based performance (7), executive walk rounds to promote management involvement in safety (8), and bar coding to improve identification.(9) I have not listed several other major techniques, such as human factors engineering, root cause analysis, and failure mode effects analysis, now used commonly in safety but drawn from other disciplines. Nor have I chronicled the mental models that have been translocated to safety, including “practice makes perfect” (popularized by many sports stars long before it found its place in health care [10]) and the application of heuristics and other cognitive psychology approaches to clinical reasoning.(11) In fact, the overarching modern paradigm for patient safety—moving away from individual blame to a richer understanding of systems thinking and engineering principles—was a marvelous example of translocational work. Reason and Rasmussen initially developed the concept of system safety outside of health care (their examples were drawn from fields like commercial aviation, oil drilling, and nuclear power).(12,13) Leape’s seminal 1994 JAMA article was the first to propose the relevance of this paradigm to patient safety.(14)

When translocating practices from other disciplines to health care, one should nearly always expect unexpected consequences. For example, as American Nurses Association president Barbara Blakeney recently described in this space, the law mandating certain nurse-to-patient ratios in California has led some institutions to cut the number of non-nurse providers, possibly compromising any potential benefits. And the recent spate of literature demonstrating negative consequences from health care information technology (IT) (15-17) is neither unexpected nor entirely unwelcome. Rather, it represents the inevitable maturation of the field, as the early literature (which looked at highly developed homegrown systems developed by IT pioneers) gives way to literature describing more broad-based implementation of store-bought systems.(18) Unlike biomedicine, where foundational work can be conducted using animals or even computer models, there is presently no shortcut to this rather messy cycle as we struggle to improve patient safety. Each “failure” brings us a step closer to understanding how practices can be successfully implemented at a wide range of institutions using a variety of real-world systems.

Why does health care depend so much on the experiences of others to improve safety? Other enterprises have been better than we have in recognizing the diverse expertise that must be mined to produce a product of the highest quality at the lowest cost. In health care, the absence of an incentive to focus on quality and safety, the huge volume of new knowledge within biomedicine itself, our siloed approach to professional training and socialization, and, frankly, professional hubris have traditionally led us to be reluctant to look beyond our own professional shores for answers. The fact that we are now willing—and increasingly able—to seek insights from aviation, manufacturing, education, and other industries, and to embrace paradigms from engineering, sociology, psychology, and management, may prove to be the most enduring benefit of the patient safety movement.

Robert M. Wachter, MD
Editor, AHRQ WebM&M and AHRQ PSNet
Professor and Associate Chairman, Department of Medicine
University of California, San Francisco

References

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1. Horig H, Marincola E, Marincola FM. Obstacles and opportunities in translational research. Nat Med. 2005;11:705-708.
[ go to PubMed ]

2. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA.2002;288:1987-1993.
[ go to PubMed ]

3. Jha AK, Duncan BW, Bates DW. Fatigue, sleepiness, and medical errors. In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Evidence Report/Technology Assessment No. 43. Rockville, MD: Agency for Healthcare Research and Quality; 2001:519-533. AHRQ Publication 01-E058.

4. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838-48.
[ go to PubMed ]

5. Barenfanger J, Sautter RL, Lang DL, Collins SM, Hacek DM, Peterson LR. Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol. 2004;121:801-803.
[ go to PubMed ]

6. Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res. 2002;37:1553-1581.
[ go to PubMed ]

7. Reznek M, Smith-Coggins R, Howard S, et al. Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine. Acad Emerg Med. 2003;10:386-389.
[ go to PubMed ]

8. Thomas EJ, Sexton JB, Neilands TB, Frankel A, Helmreich RL. The effect of executive walk rounds on nurse safety climate attitudes: A randomized trial of clinical units. BMC Health Serv Res. 2005;5:28.
[ go to PubMed ]

9. Poon EG. Effect of bar code technology on the incidence of medication dispensing errors and potential adverse drug events in a hospital pharmacy. Presented at: Society for General Internal Medicine 28th Annual Meeting; May 11–14, 2005; New Orleans, LA.

10. Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med. 1979;301:1364-1369.
[ go to PubMed ]

11. Redelmeier DA. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142:115-120.
[ go to PubMed ]

12. Reason JT. Human Error. New York, NY: Cambridge University Press; 1990.

13. Rasmussen J. Human error and the problem of causality in analysis of accidents. Philos Trans R Soc Lond B Biol Sci 1990;327:449-460.
[ go to PubMed ]

14. Leape LL. Error in medicine. JAMA. 1994;272:1851-1857.
[ go to PubMed ]

15. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11:104-112.
[ go to PubMed ]

16. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293:1197-1203.
[ go to PubMed ]

17. Nebeker JR, Hoffman JM, Weir CR, Bennett CL, Hurdle JF. High rates of adverse drug events in a highly computerized hospital. Arch Intern Med. 2005;165:1111-1116.
[ go to PubMed ]

18. Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land; 2004.

Table

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Table. Examples of Translocational Research in Patient Safety

Strategy

Non–health care example

Study demonstrating value in health care

Impetus for wider implementation

Improved ratios of providers to “customers” Teacher-to-student ratios (ie, class-size initiatives) Aiken, 2002 (2) California legislation; other pressure
Decrease provider fatigue Consecutive work-hour limitations for pilots, truck drivers Landrigan, 2004 (4) ACGME regulations limiting duty hours
Improve teamwork and communication Crew resource management in aviation Morey, 2002 (6) None yet, but on the horizon if evidence becomes more robust
Use of simulators Simulator use in aviation and the military Reznek, 2003 (7) Now required for credentialing for certain procedures; growing interest
Executive walk rounds “Management by Walking Around” in business Thomas, 2005 (8) Not required, but increasingly popular practice
Bar coding Use of bar coding in manufacturing, retail, and food sales Poon, 2005 (9) U.S. Food and Drug Administration now requires bar codes on most prescription medications; bar coding (or radiofrequency identification) may ultimately be required in many identification processes


Figure

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Figure. Translocational Research and Progress in Patient Safety

Algorithm showing the following process: Practices and approaches from outside medicine are proposed for relevance to patient safety. New clinical practice is proposed, and observational and intervention studies are undertaken. Inertia must be overcome to create a mandate/incentive to change. The intended and unintended consequences of the studies are examined and the new clinical practices are improved for re-study.

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