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Solutions for Improving Patient Safety

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  • 1. FROM THE ARCHIVES JOURNALS CLINICIAN’S CORNERABSTRACT AND COMMENTARYSolutions for Improving Patient Safety ARCHIVES OF SURGERY Can Aviation-Based Team Training Elicit Sustainable attitudes and actions given prior to, immediately after, and a Behavioral Change? minimum of 2 months after training. Results: Since 2003, 10 courses trained 857 participants in Harry C. Sax, MD; Patrick Browne, BMil; Raymond J. multiple disciplines. Preoperative checklist use rose (75% in Mayewski, MD; Robert J. Panzer, MD; Kathleen C. Hittner, 2003, 86% in 2004, 94% in 2005, 98% in 2006, and 100% in MD; Rebecca L. Burke, RN, MS; Sandra Coletta, MBA 2007). Self-initiated reports increased from 709 per quarter in 2002 to 1481 per quarter in 2008. The percentage of reports Objective: To quantify effects of aviation-based crew resource related to environment as opposed to actual events increased management training on patient safety–related behaviors and from 15.9% prior to training to 20.3% subsequently (PϽ.01). perceived personal empowerment. Perceived self-empowerment, creating a culture of safety, rose Design: Prospective study of checklist use, error self-reporting, by an average of 0.5 point in all 10 realms immediately and a 10-point safety empowerment survey after participation posttraining (mean [SD] rating, 3.0 [0.07] vs 3.5 [0.05]; in a crew resource management training intervention. PϽ .05). This was maintained after a minimum of 2 months. Setting: Seven hundred twenty-two–bed university hospital; There was a trend toward a hierarchical effect with participants 247-bed affiliated community hospital. less comfortable confronting incompetence in a physician Participants: There were 857 participants, the majority of (mean [SD] rating, 3.1 [0.8]) than in nurses or technicians whom were nurses (50%), followed by ancillary personnel (mean [SD] rating, 3.4 [0.7] for both) (PϾ .05). (28%) and physicians (22%). Conclusions: Crew resource management programs can Main Outcome Measures: Preoperative checklist use over influence personal behaviors and empowerment. Effects may time; number and type of entries on a Web-based incident take years to be ingrained into the culture. reporting system; and measurement of degree of empowerment (1-5 scale) on a 10-point survey of safety Arch Surg. 2009;144(12):1133-1137Commentary by Edward H. Livingston, MD remain common, leading some to recommend government intervention.3 The slowness to rally around patient safetyN EARLY A DECADE AGO, THE INSTITUTE OF MEDI- has been ascribed to inadequate accountability. Recommen- cine (IOM) published “To Err Is Human” high- dations have been made to deliver harsh penalties to those lighting the frequency of preventable deaths due who fail to comply with patient safety guidelines.4 to medical errors.1 According to the IOM, as many Is this strategy necessary to ensure patient safety? Notas 98 000 patients per year die needlessly in US hospitals. likely, because physicians already work in a highly account-Adopting a more rigorous safety culture should eliminate able environment. Medical care is subject to oversight bythese deaths. Given the natural inclination of the medical peer review proceedings and medical board evaluations ofcommunity to promote good care and avoid harm, it was adverse events. Errors made by physicians may result in liti-expected that medicine, as a profession, would have em- gation that is expensive and potentially career limiting. How-braced changes to prevent these errors. Five years after the ever, fear of litigation or serious harmful publicity doesreport was issued, an overview of the effects of the report not necessarily result in improved attention to patientdemonstrated that little change had occurred.2 A decade has safety. For instance, several infants treated at Cedars Sinainow passed since the IOM publication and medical errors Author Affiliations: Division of Gastrointestinal and Endocrine Surgery, Univer- sity of Texas Southwestern Medical Center, Dallas. Dr Livingston is also Contrib- uting Editor, JAMA. CME available online at www.jamaarchivescme.com Corresponding Author: Edward H. Livingston, MD, University of Texas South- and questions on p 180. western Medical Center, 5323 Harry Hines Blvd, Room E7-126, Dallas, TX 75390 (edward.livingston@utsouthwestern.edu).©2010 American Medical Association. All rights reserved. (Reprinted) JAMA, January 13, 2010—Vol 303, No. 2 159
  • 2. FROM THE ARCHIVESHospital, in Los Angeles, California, were given exces- sional societies rather than from governmental bodies or in-sively high doses of anticoagulants due to a dosing error. A surance companies.well-known actor’s involvement in these events resulted in Two recent articles9,10 in the Archives of Surgery address pa-widespread media coverage. The hospital was investigated tient safety issues. Neily et al9 presented findings from the VAby the California Department of Public Health and settled patient safety database. Mimicking the National Aeronauticswith the hospital for $750 000.5 While this episode was evolv- and Space Administration’s no-fault reporting system, the VAing, another major safety lapse occurred at Cedars Sinai Hos- developed an anonymous no-fault reporting system for nearpital. Radiation dosing for head computed tomography scan- misses and adverse events. This enabled the VA to fully char-ners was increased 8-fold over recommended doses; before acterize adverse events and near misses. Most error reduc-the error was identified, 206 patients received sufficient tion efforts such as the use of time-outs have been imple-radiation so that many experienced hair loss.6 On the other mented in operating rooms (ORs) because of the significantside of the United States, 5 wrong-site surgeries occurred potential for mistakes to occur during surgery and the highat a single Rhode Island hospital. During the 21⁄2-year profile of surgery-related mistakes. The VA found that onlyperiod in which these errors were investigated, the hospi- half of the reported events came from the OR environment.tal was sanctioned by the state medical board and fines were Wrong-site procedures occurred in non-OR settings such aslevied.7 Despite these actions, the errors continued to radiology but also during dental procedures and thoracente-occur. sis. Patient misidentification was relatively common in non-OR Slow progress in adopting practices intended to reduce settings highlighting the need to adopt the rigorous patientmedical errors requires further analysis. Fear of reprisal is identification standards implemented long ago in ORs.not working. Perhaps physicians have a sense of invincibil- Ophthalmologists and orthopedic surgeons experienced theity that erroneous actions will be committed by others and highest rate of preventable adverse events (1.8 and 1.2 eventsnot themselves. They may also be suspicious of certain pa- per 10 000 operations, respectively) resulting not only fromtient safety advocates (ie, government agencies and insur- wrong-site procedures but seemingly high rates of incorrecters whose motives may not seem pure to the practicing phy- device implantation. Root cause analyses demonstrated thatsician). Another possibility is that with lower reimbursement communication problems were the most frequent cause ofrates and increased bureaucracy associated with medical prac- preventable errors.5 The VA implementation of a system-tice, physicians simply do not believe they have the time to wide mechanism for no-fault reporting has done a great dealdevote to safety training courses and additional practices to show that adoption of risk-free communication amongadopted in the name of safer practices. health care workers can achieve the same results as were Physician-driven processes for change are more likely to proven effective in the airline industry for enhancing safetysucceed. A prime example has been the Veterans Adminis- awareness. From this VA analysis, the source for prevent-tration (VA) National Surgical Quality Improvement Pro- able errors was identified leading to a pathway for error re-gram (NSQIP). The NSQIP was started by a small group of duction. Use of communication tools such as checklists andsurgical leaders within the VA who were anxious to pro- more rigorous attention to patient identification in non-ORvide better outcomes for their patients. The project was ini- settings can reduce preventable medical errors.tially resisted by their colleagues who legitimately feared that In an article in the December issue of the Archives of Sur-aggregated outcomes data might be misinterpreted and used gery, Sax et al10 reported results of implementation of an air-to penalize clinicians charged with caring for very sick, high- line industry safety practice to medical care. Crew re-risk patients. Administrators were not enthusiastic about the source management training is now standard within theprogram because of its expense (Ralph G. DePalma, MD, airline industry. Crew resource management was devel-former National Director of Surgery, Veterans Health Ad- oped following investigations in which poor communica-ministration, written communication, December 2009). With tion was identified as the leading cause for fatal crashes. Astime, the process of assessing and acting on risk-adjusted the report by Neily et al9 demonstrated, inadequate com-outcomes information resulted in substantial reductions in munication is one of the most important causes of prevent-mortality in the VA health care system.8 As the program’s able medical errors. Adoption of crew resource manage-successes became evident, it became accepted by surgeons ment in the medical environment seems logical as a meansand administrators and has been adopted by the American for error reduction. Crew resource management includesCollege of Surgeons as its principal means for monitoring review of detailed checklist prior to flying and also incor-surgical care quality. The NSQIP’s success concurrent to porates processes ensuring free and open communicationstalled efforts to promote patient safety in other clinical ven- between all members of a flight crew, especially facilitatingues most likely reflects the differences between the top- subordinate employees’ ability to openly discuss concernsdown appeal of a government body (the IOM) and the bot- they have about flight safety with those in the upper hier-tom-up implementation of the NSQIP. Improvement in the archical ranks. Procedures are used to ensure faultless er-safety culture in medicine will more likely succeed if the ror reporting ensuring that process improvement takes pre-impetus for change comes from clinicians and their profes- cedence over assignment of blame.160 JAMA, January 13, 2010—Vol 303, No. 2 (Reprinted) ©2010 American Medical Association. All rights reserved.
  • 3. FROM THE ARCHIVES Sax and colleagues10 report their experience with imple- part, by their safety reputation. Although preventable er-mentation of these same techniques in the OR environ- rors are rare, processes adopted to minimize their risk arement. Use of preoperative checklists increased to 100%, er- not and are readily measurable. Clinician participation inror reporting doubled and, in general, those working in the team training and the use of checklists and other devicesOR environment felt more empowered to address deficien- proven to lessen the risk for preventable error might pro-cies they noticed. Processes such as those outlined by Sax vide evidence for health care organizations’ seriousness aboutet al will, by necessity, become routine components of daily patient safety. Much as today’s quality indicators are reallypractice.6 measures of processes of care rather than outcomes, pa- More must be done to eliminate preventable medical er- tient safety efforts can be documented by physician partici-rors. Despite IOM reports and numerous editorials high- pation in these activities. Publication of compliance withlighting the need to adopt a stronger safety culture in medi- patient safety measures similar to what the Centers for Medi-cine, little has changed. It is natural to resist change. The care & Medicaid Services now does with quality-indicatorinitial reaction to the IOM report 10 years ago was denial. compliance may prove to be the most effective means of pro-The report was widely perceived as having exaggerated the moting the patient safety movement within medicine.problem of preventable deaths. Nevertheless, reports of Financial Disclosures: None reported.wrong-sided surgeries recently have attracted more atten- Disclaimer: Dr Livingston, a JAMA Contributing Editor, was not involved in thetion because they are universally viewed as completely pre- editorial review of or decision to publish this article.ventable and unacceptable; this problem can no longer beignored. The report by Neily et al9 shows that completely REFERENCESpreventable errors occur as frequently in the OR as outside 1. IOM Committee on Quality of Health Care in America. To Err Is Human: Build-of it, requiring all health care professionals to engage in pro- ing a Safer Health System. Washington, DC: National Academy Press; 2000.cesses to eliminate preventable error. 2. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005;293(19):2384-2390. Because denial of the patient safety problem is no longer 3. Pronovost PJ, Faden RR. Setting priorities for patient safety: ethics, account-an option, how will the safety culture improve in the deliv- ability, and public engagement. JAMA. 2009;302(8):890-891.ery of medical care? Analogies to the airline industry are use- 4. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in pa- tient safety. N Engl J Med. 2009;361(14):1401-1406.ful. Crew resource management processes were developed 5. Blankstein A. Quaids settle with hospital. Los Angeles Times. December 16,and widely accepted within the industry following high- 2008. 6. Zarembo A. Cedars-Sinai radiation overdoses went unseen at several points.profile preventable crashes. If passengers lose confidence Los Angeles Times. October 14, 2009.in the safety of air travel, they will not fly. Public confi- 7. Letter to CEO of Rhode Island Hospital from the Rhode Island Department of Health (November 2, 2009). http://www.health.ri.gov/discipline/hospitalsdence in airline safety is an essential foundation of the air- /RhodeIsland200911.pdf. Accessed December 4, 2009.line industry business model. Even though patients are less 8. Bush RL, DePalma RG, Itani KM, Henderson WG, Smith TS, Gunnar WP. Out-afraid of hospitals than airplanes, nonetheless, high-profile comes of care of abdominal aortic aneurysm in Veterans Health Administration facilities: results from the National Surgical Quality Improvement Program. Am Jincidents such as those that occurred in Los Angeles, Cali- Surg. 2009;198(5)(suppl):S41-S48.fornia, or Rhode Island still generate concern. 9. Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and out- side of the operating room. Arch Surg. 2009;144(11):1028-1034. Change might be driven by patients. In the future, phy- 10. Sax HC, Browne P, Mayewski RJ, et al. Can aviation-based team training elicitsician and hospital selection by patients may be made, in sustainable behavioral change? Arch Surg. 2009;144(12):1133-1137.©2010 American Medical Association. All rights reserved. (Reprinted) JAMA, January 13, 2010—Vol 303, No. 2 161

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