Quality departments key to solving medical error crisis
Quality departments key to solving medical error crisis
Examine your policies and procedures for solutions
From Veterans Affairs hospitals to private and public health care, patient safety has become a hot issue and a top priority for health care organizations across the country. And while it’s still unclear what national initiatives will be set up to address the problem of medical errors, it’s becoming increasingly apparent that quality departments will have to play an active role in reducing errors at the hospital level, both with regard to data collection and process improvement.
Michael Leonard, MD, anesthesiologist with Kaiser Permanente and director of Kaiser’s Surgical Services in Denver, spearheads the medical error/patient safety initiative for Kaiser’s Colorado region. "We’ve been interested in this for some time," he says. "And one of the things we’ve come to understand is that in medicine, we’re trained to not make mistakes. Making mistakes is related to not being worthy. We’re in a culture where we’re very uncomfortable talking about our mistakes. But people aren’t perfect, and they will make mistakes. So what we need to do is provide education around the whole concept of human performance and error."
To that end, Kaiser Permanente in Colorado gave a seminar for about 100 doctors and nurses last October. "When I talk to groups like this," Leonard says, "I discuss my mistakes." He goes on to describe a recent situation in which two drugs that looked alike (both were in small yellow vials) but had different functions were stored together. Leonard was working with a very complicated, busy surgery case and had a lot of things handed to him as the surgery was wrapping up. When the surgeon said surgery was over and it was time to wake the patient, Leonard realized that he’d confused the look-alike drugs, using the one that further anesthetized the patient rather than the one that reverses the effects of anesthesia.
"My approach was to say, You know what? I made a mistake. We’ll need to stay another hour to wait for things to stabilize so we can fix this.’" Leonard eventually woke the patient, who was fine. He also explained the error to the patient’s wife.
"A bit later, I was on my way to the pharmacy to discuss the problem and how to resolve it," he continues. "I ran into several of my colleagues and told them what had happened. They all told me it had happened to them, too, but nobody had ever talked about it." The Kaiser pharmacy now stores those two drugs separately, one with a red sticker on it as a flag.
"We’ve gotten amazingly positive reaction to this concept of openness," Leonard says. "After our October seminar, it opened the door for everyone to start discussing their mistakes.
"We have the ability to measure and change behavior," he says.
Michelle Boylan, DMC, RN, manager of quality and outcomes at University Hospital in Denver, says the hospital reviewed the Institute of Medicine’s report To Err Is Human and is creating a task force to focus on issues of patient safety and medical errors. "We don’t know what we’ll find," she acknowledges, "but we look at it as a positive opportunity to create efficiency and effectiveness in the system." She says that in order to change the culture of silence that is the basis for so much of the problem, state medical boards must develop a new philosophy, much as hospitals are now doing.
"One piece that needs to be cracked is that we still exist in a punitive environment regarding mistakes," notes Leonard. "We need to find a balance between flagrant, out-of-bounds errors as opposed to complex situations that require much concentration and focus. Aviation says, Play by the rules, and we’ll support you. If you’re flagrantly violating rules, then it’s your butt.’ Medicine can say this too."
Leonard says an important part of eliminating mistakes lies with technology. "Normally, when a patient arrests, the more junior nurses wait for a doctor to show up and take action. People get into doing things they’re comfortable with, which may not be what a patient needs. In the case of a cardiac arrest, we know that without cardiac life support, the chance of survival for the patient drops about 10% each minute."
So how to solve the problem of the patient’s need for instant action? "We’re now teaching nurses and other members of the medical teams to use the automatic defibrillator, a small device now carried on airplanes which can shock the heart back into its normal rhythm. We’re teaching them that when a patient arrests, you put the defibrillator on him and turn it on. You don’t wait for the doctor." He describes the defibrillator as an important device that takes human performance out of the equation and greatly reduces the chance for error.
He adds that Kaiser does outpatient clinics teaching basic cardiac life support. "We’re not getting lost in esoterica. We’re talking about saving lives, getting our medical workers to define the goal of best patient care and making junior people feel more comfortable about their actions."
Computerized queries can reduce errors
John M. Eisenberg, MD, director of the Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD, recommends implementing a computerized query system to question a physician’s prescription for a patient whom the computer finds is already taking another drug that might interact adversely.
"For clinicians, it might mean going on-line and checking the National Guideline Clearinghouse to see if there’s an evidence-based guideline that could be put in place in your hospital or health plan to improve treatment," Eisenberg recommends. (The National Guideline Clearinghouse can be accessed at www.guideline.gov.)
"But," he adds, "error-reducing systems changes do not have to be big changes. For example, clinicians can start asking patients to bring in all their medicine bottles to identify all the prescriptions they are receiving. Or clinicians can back up their memory by keeping lists or reminding themselves that not all patients can read well enough to understand the labels on their prescription bottles."
The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, says its sentinel event policy is designed to encourage self-reporting of medical errors, to learn about the frequencies and underlying causes of these events, to share lessons learned with other health care organizations, and to reduce the risk of future occurrences.
When such an incident is reported, the organization must prepare a root-cause analysis and action plan within 45 calendar days of the event and present it to the Joint Commission.
"But it is abundantly clear that no reporting system for serious errors can fulfill its objectives without congressional help," said Dennis S. O’Leary, MD, president of the Joint Commission. "Without federal legislation, the Joint Commission’s error reporting program and others like it will continue to fall short of their intended goals. This is true whether the reporting framework is public or private; mandatory or voluntary; national, state, or local."
O’Leary’s remarks came during the last in a series of hearings on patient safety conducted by the Senate Committee on Health, Education, Labor and Pensions and the Subcommittee on Labor, Health and Human Services, and Education of the Senate Appropriations Committee.
Essential to the creation of an error-reduction strategy, according to O’Leary, are these five components:
• creation of a blame-free, protected environment that encourages the systematic surfacing and reporting of serious adverse events;
• production of credible root-cause analyses of serious adverse events;
• implementation of concrete, planned actions to reduce the likelihood of similar errors in the future;
• establishment of patient safety standards that health care organizations must meet;
• dissemination of lessons learned from errors to all health care organizations at risk for serious adverse events.
Says Kaiser Permanente’s Leonard, "For us, there are three key pieces: We must have good data — we have to know what the error rates are and what the environment’s like; we need systems to deliver change and measure the effects; and we need to assess the culture." (See related story in the Quality-Co$t Connection column, p. 80.)
However, not all errors occur in hospitals. Doctors’ offices, nursing homes, pharmacies, and home care agencies are also vulnerable. As an example, the Massachusetts State Board of Registration in Pharmacy estimated that 2.4 million prescriptions are filled improperly each year in the state. But an unrelated 1999 study showed that medication errors fell by 66% when a pharmacist accompanied doctors on medical rounds.
The AHRQ says the specialty of anesthesia has reduced its annual errors from as many as 50 million in the 1970s to 5.4 million currently with the use of standardized equipment, protocols, and guidelines. It also cites a hospital in the Department of Veteran Affairs that has cut medication errors by 70% by using hand-held, wireless computer technology and bar-coding. This kind of system will soon be incorporated into all VA hospitals.
This helps underscore the Institute of Medicine’s finding that most medical errors are systems problems rather than the result of individual negligence or misconduct.
Eisenberg uses statistics to help drive home the seriousness of the patient safety problem. "More people die from errors than from auto accidents," he says. "More people die from errors than from breast cancer. More people die from errors than from AIDS. But if you think about the investment that we’re making in research to understand why these errors are made and what we can do to prevent them, that investment pales in comparison to what we’re spending on breast cancer and AIDS."
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