Toward a Culture of Safety, Part 1

Since we launched our Adverse Events Reporting Database a little over a year ago, we’ve learned a lot, including some interesting things about how acupuncturists react to the idea of an Adverse Events Reporting Database. This is the first of a series of blog posts about the AERD which will form the basis for a free online CEU class, coming later this summer. POCA's AERD is here: https://acupunctureconsumersafety.net/

But first, let’s talk about acupuncturists’ reactions to our AERD, and what we can learn from them. Here, in no particular order, is a list of some of the objections we’ve heard:

There’s no need for an AERD for licensed acupuncturists because acupuncture provided by L.Acs is so safe/Acupuncture adverse events don’t happen often enough to even worry about/You’re defining adverse events too broadly/Patients are manipulative and make things up so their reports can’t be trusted/ You shouldn’t take minor events like bruising and bleeding so seriously, why even report something like that/What if people deliberately submit misleading reports to make us look bad/Actually this entire project makes us look bad/We’re going to get blamed for events caused by poorly trained physical therapists and chiropractors/You shouldn’t collect reports that you can’t verify are real/Did anyone mention this makes us look bad/WHAT ABOUT UNDERTRAINED PTS, THEY’RE THE REAL PROBLEM/ We don’t need an AERD when we already have this

Let’s back up, like way way way back, and talk about a culture of safety.

That’s a concept that’s important in a lot of integrative settings, such as hospitals and outpatient rehab and opioid treatment facilities. Despite being avidly interested in integrative medicine, acupuncturists are late to the party, as it were, when it comes to embracing the concept of a culture of safety. You could argue that a culture of safety is an imperative in the context of biomedicine, since the third leading cause of death in the US is medical error — but not really needed in the context of acupuncture, which is much less invasive and much safer.

However, we’re going to argue that even though acupuncture errors aren’t killing anybody on a regular basis, embracing the concept of a culture of safety would be a very good thing for the acupuncture profession — and using the AERD is a low-risk way to do that.

In her 2013 POCAfest presentation about starting Guelph Community Acupuncture with POCA’s first microloan, Lisa Baird said, “Thank you for providing space for me to say how I’ve fucked up. (This culture of shared error on POCA is magnificent. Every time one of us says “I screwed up here,” it opens up even more space for someone else to do the same.)” The POCA Cooperative has spent a lot of time and energy creating an environment of social safety around starting up and running a business, and it’s one of the things that new members sometimes comment on — what a relief to not have to pretend that you know everything, what a relief to not have to act like you’re not making mistakes, because after all, people learn by making mistakes.

One hospital safety expert describes a culture of safety in a similar way, but for clinical care: “So a culture of safety is the culture of an organization that focuses on the safety of the care that's delivered. In an organization that has a strong culture of safety, providers are comfortable talking about errors and near misses and actual harm and they don't fear reprisal. They understand that when discussions like this are had, that the spirit of those will be understood, and that they'll be used to make the care that's being delivered safer.”

Especially now that POCA has an acupuncture school, we think it’s important to be able to talk about clinical mistakes and negative outcomes in an environment that doesn’t involve blame. If it’s not socially safe to talk about what can go wrong in clinic, it’s not possible to learn anything collectively from those events, whether they’re the result of errors or plain old bad luck or more complicated things like how the neurobiology of pain and trauma affect patients’ perceptions.

We definitely agree that, as far as we can tell at this point, adverse events for acupuncture are infrequent and serious adverse events are quite rare. However, adverse events do happen — their incidence is not zero — and so:

1) if you’re doing a high volume of treatments over a long period of time (hello, successful community acupuncture clinics), your odds of dealing with adverse events go up, just because that’s how probability works;

2) when adverse events happen, they have the potential to be stressful — possibly very stressful — for both practitioners and patients, and the more that adverse events are automatically associated with blaming the practitioner, the more stressful (and isolating) they will be;

3) acupuncturists have quit their practices over adverse events, including ones in which they weren’t “at fault” — see above, AEs can be stressful, isolating and hard to recover from;

4) if you’re doing a lot of pain management (hello again, successful community acupuncture clinics), you will sometimes encounter negative reactions to the treatments you provide, because that’s how the neurobiology of pain works.

There’s a huge need in our society for non pharmacological interventions for pain management. The POCA Cooperative is already doing enough treatments to expect, statistically, to encounter adverse events, and we should be aiming to provide many, many, many more treatments if we’re even going to scratch the surface of the actual need — which means dealing with more adverse events, not fewer. We don’t have enough acupuncturists already and we can’t afford to lose any for preventable reasons. 90% of acupuncturists are self-employed, and self-employment is already stressful enough by itself without adding a layer of blame and isolation for practitioners who experience adverse events. We believe if you really look at the numbers (of patients who need acupuncture, of practitioners, of the relative incidence of adverse events), they make a case for acupuncturists to get serious about building a culture of safety.

That goes double for acupuncturists who want to work in integrative settings. In healthcare, collecting data about adverse events, errors, and even near misses — no matter how infrequent! — is just something that grown-ups do. Claiming that acupuncturists are such special safety snowflakes that we don’t even have to think about this topic isn’t a good way to be taken seriously by other healthcare providers and institutions (which is something a lot of acupuncturists say they want, right?). Tracking adverse events and errors is not going to make us look bad to anybody who understands how healthcare delivery works in the real world; in fact, the opposite is true.

While we’re on the topic of being taken seriously by other providers, you know what else isn’t conducive to that, and what can really make us look bad? Being interested in safety data only insofar as we can weaponize it against other providers. This is the opposite of building a culture of safety. Setting the expectation that adverse events are solely a function of undertrained, irresponsible people trying to poach our practices is totally not helping, okay? Building a culture of safety is a lot more complex than arguing about regulation, legislation, or minimum hours of training for acupuncture.

Building a culture of safety is something we do for ourselves, regardless of who else is watching; it’s a form of proactive, professional self-care as well as a way of taking better care of our patients. For POCA Tech, building a culture of safety is an important way of supporting the next generation of acupuncturists, and for POCA, it’s a way of investing in the acupuncturists we want to keep.

Up next: Toward a Culture of Safety, Part 2: Pain Management

Author: lisafer