|
Medical director coordinates patient safety series in journalThe first in a series of articles on patient safety appeared in the March 20 issue of the international medical journal, The Lancet.Authored by MUSC Medical Director John Heffner, M.D., and his British colleague, Julian Bion, M.D., the first article in the Inpatient Safety series, “Challenges in the Care of the Acutely Ill,” reviews patient safety issues. Because of their reputations and interests in this area, Heffner and Bion were invited by The Lancet's editors to organize an international group of experts on patient safety for the five-part series. Heffner and Bion selected specific safety topics and found the best people in the field to author the remainder of the series. The article suggests a general model for improving patient safety through increased staff and patient awareness, improved medical education and training methods, and safer systems. The article references an Institute of Medicine report estimating that 44,000 to 98,000 patients die each year as a result of clinical errors. Heffner and Bion said that the last link in a chain of events, usually a doctor or nurse, appears to be the immediate cause of adversity. But the real culprit is a system failure that must be addressed. “That can’t be done if the error isn’t reported,” said Heffner. “It is estimated that of all mistakes made by health care providers, only 5 percent are reported. We’re trying to create a patient safety culture without a punitive approach. It is only when an error is reported that the system can be changed to alter the sequence of events leading to the error.” The fear of lawsuits also comes into play. Heffner and Bion say hospitals need data collection systems that allow providers to enter information anonymously and easily , using Intranet-based online systems with automated analysis and reporting. “The system must be set up to prevent errors,” said Heffner. “Just as you can’t start up your car when it is in gear, we have a bar code system making it impossible to give a patient the wrong medication.” If a medication bin holding medicine for a specific patient cannot be opened without swiping a unique bar code, mistakes can be prevented. “We must train our people to use a team approach,” he said. Using an airline analogy, the pilot is in charge, but the co-pilot can identify a problem or an unsafe circumstance. Hospital staff must see themselves as a multidisciplinary team in which all members are empowered and encouraged to speak up. For example, in the operating room, the surgeon is the pilot but the anesthesiologist and nurses are the co-pilots. Medical students or clerical staff dealing with paperwork could be in a position to recognize a potential problem. “No one should feel intimidated, and everyone should be free to speak up and be an advocate for the patient,” said Heffner. Still, the health care system is more complex than the airline industry. Planes are scheduled to take off and land, and in general, there is a great deal of predictability. Comparing the health care environment to a battlefield might be more accurate. The environment is chaotic, with unpredictable workloads and uncertainty about individual patient outcomes. Health care is unique and should learn from other industries, the article suggests. The field needs models to address the unique challenges of the acute hospital setting. Another problem is physician fatigue. Residents traditionally are overworked. The article echoes changes that limit hours of house staff, emphasizing that there is no magic solution. As resident hours are cut back, so is continuity of care. “This challenges us to look at better communication systems, so key patient information can be passed from the house staff member going off duty to the one coming on,” said Heffner. While not specifically addressed in The Lancet article, Heffner believes the future should hold a much greater reliance on simulation. Physicians-in- training and those in practice should be able to go to a simulation laboratory to practice new procedures in a safe environment. He explained that simulation in its simplest form could be a wooden mock-up of a ventilator with which medical students can learn how to work switches or respond to alerts. A more complex simulation could be a cardiac catheterization lab with a mannequin as patient. This sophisticated simulation is not readily available yet, but Heffner sees it in the near future. MUSC just purchased a high-tech, electronic mannequin with which trainees can learn how to start central venous catheters, run resuscitations, and intubate the patient for an airway. A computer is connected to the mannequin, so rare catastrophic events can be simulated and the trainee’s response tested. The wave of the future is outside report cards. Increasingly, hospitals will be expected to report safety data to governmental agencies, payers, and other groups. Heffner said the public will hold physicians, physician practices, and hospitals more accountable for adhering to the best practices of care. For example, the Centers for Medicare and Medicaid Services collect information from hospitals regarding how many patients were appropriately vaccinated for pneumonia and influenza, how many received guideline-recommended medications for heart failure, and how many received antibiotics for treating pneumonia in a timely fashion. Friday, March 26, 2004
|