How are health care providers developing ways to improve patient safety?
A major patient safety initiative study showed there are nearly 98,000 deaths related to medical errors per year. To address this issue, we looked at other industries with an obsession with safety, like nuclear power plants or air travel. Why is their error rate so low? What is inherent in these industries that allows them to achieve such high results?
We found that these industries have certain characteristics, like this obsession with safety, and a culture where everyone from the newest hire to the CEO can identify safety risks and feel comfortable addressing those risks.
Medicine was the complete opposite. Doctors were at the top and everybody else had to fall in line. Front line employees didn’t feel secure enough to bring up any safety concerns. By empowering people to speak up and bring safety concerns up to administrators, you can promote a culture of safety.
What types of programs have been developed to improve patient safety?
One major initiative is medication reconciliation. Basically, this process checks if patients are taking the medications prescribed for them correctly and with consistency.
Many patients aren’t taking their medications correctly, not because they don’t want to, but because the instructions leave room for interpretation.
So we developed a process to make sure that when someone has an interaction with a caregiver at one of our facilities, we check the medication list and ensure that they are taking the medications prescribed to them — correctly.
What is being done to reduce medical error?
There are three key components: communication between individuals, human factors and simulation training.
Seventy-five percent of medical errors are due to communication problems. So we used a method of communication called SBAR to develop a concise way to communicate more effectively between everyone in the organization.
S stands for situation, the headline. B is the background — what led up to that point. A is your assessment of the situation. R is your recommendation. So if you have a patient in cardiac arrest, instead of giving too much information, you can communicate quickly and clearly.
We train our people on the human factors — innate human characteristics that can lead to errors: fatigue, fixation on certain tasks, tunnel vision. Then, we determine what we can do in our systems to reduce those types of errors.
We also rehearse emergencies, like they do in the airline industry. Every pilot has to clock so many hours in a flight simulator. We created something similar. Say someone goes into cardiac arrest in a doctor’s office. You have to train the staff for what to do in that situation.
One of the first areas we looked at was the perinatal arena (the time period immediately before and after birth). Based on the amount of payouts we have, we know that that is where there is the highest risk. Studies of medical errors in the perinatal unit show you can boil them down to five main causes. So we started rehearsing these causes in real time, with real staff performing their normal functions. These medical simulations have been expanded to almost every department in the ongoing effort to reduce adverse events and prevent the preventable.
Dr. Charles Zonfa is the physician director of risk management and patient safety for Ohio Permanente Medical Group.
