Improving Patient Safety: Lessons from a Military Operations Framework

目前的医疗服务系统是在一个反应性的框架下运行的，在这个框架下，一线护理人员和领导者在事件发生时和发生后对不良事件做出反应。For example, patients may developacute kidney injury(AKI) when care teams don’t preemptively identify threats associated with prolonged exposure to medications known to be toxic to the kidneys. Or a patient may get apressure injury(PI) when clinicians don’t follow prevention guidelines. In both scenarios, care teams respond once harm has occurred, versus responding to early warning signs of risk.

But what if healthcare adopted a proactive framework, anticipating events and employing an appropriate mitigation strategy that optimized the relationship between data and technology and human decision making?

在主动的情况下，该组织将使用自动化监控系统和方法在患者遭受伤害之前检测AKI和PI情况。自动化监控系统能够持续监测数据，并提供潜在风险的态势感知。通过主动感知，自动化监控为临床医生及其组织提供分析，在损伤发生前将注意力集中在威胁上，从而在患者接受治疗时实现预防或早期缓解。

Staying Left of Bang: Constant Vigilance

其他高风险、后果严重的职业和实践——从军事到灾害管理——都是在积极主动的框架下进行的，因为被动应对的后果将是毁灭性的，有时甚至是致命的。一个被称为“爆炸左翼”的作战军事概念强调在事件发生前的态势感知，或“爆炸”发生。在战斗中，bang可以是一种攻击;在医疗保健中，bang可以是任何数量的不良事件(例如，医院获得性疾病[HACs])，增强情境感知可以减轻或预防。

In their book “Left of Bang,” former active-duty Marine Corps officers and instructors, Patrick Van Horne and Jason Riley, describe methods for increasing sensitivity to and staying in constant vigilance to threats before they happen. Given the parallels between military and healthcare operations (life-and-death decision making, noisy and chaotic environments, and more), left-of-bang situational awareness offers a model for moving healthcare from a reactive to a proactive framework that supports better care and lower costs.

The Downside of a Reactive Framework

在军事和医疗场景中，我们的目标都是保持主动，保持“左枪法”，因为“右枪法”意味着事件已经发生，只留下应对后果的选项。在医疗保健中，依赖于反应性反应是昂贵的，并带来了严重的临床和操作缺点。Reaction doesn’t promote awareness or allow for intervention, mitigation, and prevention and can produce several negative outcomes, including diseases, harm events, clinician burnout and turnover, and more (Figure 1).

Healthcare relies on voluntary reporting, in which a team member recognizes and reports an adverse event, with either paper-based or electronic means, to another team member to investigate. With multiples steps (such as identifying and reporting the event before intervention), voluntary reporting is not only inefficient, but studies have shown it’s not accurate or comprehensive, detecting only about14 percent所有原因的伤害事件。

安全漏洞及其导致的并发症一直存在于医疗机构中，对患者、临床医生和卫生系统构成了重大负担。各组织迅速查明和干预此类事件的能力各不相同。Timely recognition and appropriate intervention of patient conditions that represent clinical risk or early onset of preventable injury is essential for ensuring optimalpatient safetyin all care settings.

从右侧(反应性地)接近患者的安全，就像司机同时看挡风玻璃和后视镜一样，在识别早期预警信号方面是无效的——到处都是盲点。为了解决汽车安全盲区问题，如今的汽车配备了多种安全系统，可以同时提供主动和被动安全监控——很多汽车上至少有10个主动安全系统和6个被动安全系统。医疗保健组织必须遵循并采用主动和被动安全系统，以提供持续的警惕、专注和对未决和现有的患者安全威胁的意识。

由于自愿报告的局限性，患者安全盲点可能导致被忽视的伤害事件、反应性安全系统和有缺陷的数据。这些因素加在一起，增加了程序上的伤害、与劳动力相关的、以及未被识别的伤害的风险。

Better Visibility: Broadening Healthcare Situational Awareness

Health care can overcome its safety blind spots with broader situational awareness. Left of Bang authors Horne and Riley use Jeff Cooper’s Awareness Color Code Chart to describe four levels of situational awareness or alertness: white (unaware); yellow (alert and aware but also calm and relaxed); orange (heightened awareness); and red (taking decisive and immediate action). The goal is a seamless transition between the levels.

Cooper’s color codes translate aptly to the healthcare setting:

• White: Healthcare mostly operates on the white level. Care teams are tending to the tasks at hand but largely unprepared for disruption and unaware of the conditions around them. This level is a low state of psychological awareness and of the physiological arousal that readies people to take action.
• Yellow: Care teams should aim for a yellow awareness level most of the time; here, they continuously understand the safety vulnerabilities of day-to-day healthcare. They are psychologically alert, physiologically aroused, prepared for something to happen, and ready to take action.
• 橙色:在橙色干预层面，护理团队已经准备好使用所需的技能和工具来应对事件。当他们意识到安全事件时，心理意识就会下降。因此，他们只意识到事件，而不再意识到周围的环境，但他们的生理状态会增加，让团队成员做好采取行动的准备。
• 红色:在红色级别，护理团队开始行动。他们的心理意识甚至下降得更低，他们把注意力集中在手头的问题上。技术通过扫描数据、让团队了解未决或现有的危害并确定适当的行动(例如，Health Catalyst®患者安全监视器™套件:监控模块)来支持这种主动状态。世界杯葡萄牙vs加纳即时走地

The Right Technology Supports a Proactive Solution

An effective proactive healthcare delivery tool is a cloud-based module that monitors near real-time patient data from multiple sources and signals clinical attention when a patient is experiencing an adverse event or exposure to conditions that can lead to injury. The Patient Safety Monitor (PSM) Surveillance Module, for example, serves as central command for healthcare decision making.

With safety monitors and triggers, the Surveillance Module enables remote patient surveillance (Figure 2). It detects injury at an early stage or when it’s about to happen, alerting care teams in time to intervene and prevent or mitigate harm. The model incorporates evidence-based guidance intervention into its actions based on different types of events, allowing teams to manage, mitigate, and prevent.

Safety measurement and monitoring that leverages a proactive, left-of-bang approach builds on and reinforces the five-dimensional safety framework outlined in 2015 aBMJ Quality & Safetypaper. The publication aimed to provide a structure for determining whether a healthcare organization was safe:

1. Past harm: Has patient care been safe in the past?
2. 可靠性:我们的临床系统和流程可靠吗?
3. 手术敏感性:今天的护理安全吗?
4. Anticipation and preparedness: Will care be safe in the future?
5. Integration and learning: Are we responding and improving?

采用并内化这一安全测量和监控框架使医疗保健组织处于一种持续的黄色意识状态(根据Cooper的颜色代码，心理上警惕、积极准备和充分意识到日常安全漏洞。

Improving Patient Safety by Keeping Healthcare Left of Bang

多年来，医疗保健组织一直依赖于被动的安全方法，主要是依赖于质量和安全措施的法规遵从性。这种反应模式导致了一种错误的安全感，事实上，通常不能保证患者的安全状态或安全的改善。

A proactive, left-of-bang healthcare alternative to voluntary reporting leverages electronic surveillance, comprehensive patient data, and pattern recognition (artificial intelligence/machine learning) to alert care teams when an event has occurred or is likely to occur. As a result, teams stay in constant vigilance.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

1. Healthcare Safety Culture: A Seven-Step Success Framework
2. How to Use Data to Improve Quality and Patient Safety
3. Healthcare Safety Culture: A Seven-Step Success Framework
4. Patient Safety Best Practices E-Book: The Intersection of Patient Care and Technology
5. Introducing the Health Catalyst Monitor™ Patient Safety Suite: Surveillance Module

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