Do you think that it is your responsibility, after boarding a plane, to ask the captain if he had radio communication with the tower? Yet, policymakers now encourage patients to ask healthcare providers an equally basic question-have they cleansed their hands before rendering care? Is this patient safety gone awry?

More than a decade ago, the Institute of Medicine's report "To Err Is Human: Building a Safer Health System" debunked the widespread perception that patients were safe when receiving health care and stimulated efforts to improve healthcare safety. James Reason's (2000) seminal article set the stage for many of these initiatives. His analysis of safety errors revealed that when weaknesses occurred in various protective layers in succession, safety failures occurred, much as if holes in Swiss cheese aligned, allowing a mouse to run through them. He called for a paradigm shift from individual error and blame to focus on system redesign.

Today, many patient safety initiatives feature technological safeguards in the clinical arena, standardization of procedures, and electronic documentation. The majority of these use inductive, fairly linear approaches designed to "close the holes." However, Reason noted that, unlike in slices of Swiss cheese, the holes in these layers change in size, shape, and position with time and circumstance. The results of many safety initiatives have been varied and are often difficult to sustain. Healthcare providers revert to old patterns and create "work-arounds" in onerous layers, including silencing alarms or circumventing bar code patient verification procedures.

It is difficult to sustain behavior change. For example, baseline statistics hover around 40%-60% on provider compliance with hand hygiene. System redesign includes instructional mandates, better cleansing products, and environmental modification, yet hand hygiene improves only to 70%-80% and declines without reinforcement. Now, to close the hole in the last cheese slice, patients are asked to check on providers' hand hygiene.

A second wave of patient safety research is needed to understand the relationship between technological innovation and provider motivation. Nurses who directly interface with patients recognize system flaws that can undermine patient well-being; clinical experts and researchers need to lead in the design, execution, and evaluation of patient safety innovations. Research is needed to more fully explicate how nurses and others perceive patient safety innovations, with emphasis on their personal ability to provide care.

In new paradigms of care, attention must be paid to questions arising from the standardization-individualization conundrum. Using hand cleansing as an exemplar, if patients monitor provider hand hygiene practices, does this (a) improve provider compliance? (b) reduce patient infections? (c) affect the anxiety levels in sick individuals? (d) undermine provider trust or (e) foster nurse-patient collaboration? One final thought-although it may be useful for patients to ask their providers about hand hygiene, should they really have to?

Judith A. Vessey, PhD, MBA, FAAN

Boston College

[email protected]

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