Contact: Ellen Bank
843.792.2626
May 18, 2004
CHARLESTON, SC -- The first in a series of articles on patient safety will
appear in the March 20 issue of the international medical journal The Lancet.
Authored by MUSC Medical Director John Heffner, M.D., and his U.K. 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 editors of the journal to organize an international group of
experts on patient safety for the five-part series. They selected specific safety
topics to address and found the best people in the field to author the remainder
of the series addressing these issues.
The article suggests a general model for improving patient safety through increased
staff and patient awareness, improved medical education and training methods,
and the institution of 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. The authors
say that the last link in a chain of events, usually a doctor or nurse, appears
to be the immediate cause of an adverse event. But, the real culprit is a system
failure, and this is what 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.”
Fear of lawsuits is another factor that comes into play. The authors say that
hospitals need data collection systems that allow providers to enter information
anonymously and easily through Intranet-based online systems with automated
analysis and reporting.
“The system must be set up to prevent error,” 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 bar code unique to that patient, mistakes are 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 is in the position
to identify a problem or an unsafe circumstance. They 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.
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.
The health care environment is much more complex, and the analogy to a battlefield
might be closer. The environment is chaotic, with unpredictable workloads and
uncertainty about individual patient outcomes. Health service is unique and
should learn from other industries, the paper suggests. Models are needed that
address the unique challenges of the acute hospital setting.
Another problem is physician fatigue. Residents traditionally have been overworked.
The article echoes changes going on limiting hours of house staff. The article
emphasizes that there is no magic solution as resident hours are cut back, there
is less 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 paper, but related to the issue
of training, Heffner believes the future should hold a much greater reliance
on simulation. Physicians in training and those in practice doing a new procedure
should be able to go to a simulation laboratory to practice the procedure in
a safe environment. He explained that simulation in its simplest form could
be a simple wooden mock-up of a ventilator where medical students can learn
how to work switches or respond to alerts. A more complex simulation could be
a totally simulated cardiac catheterization lab with a mannequin as patient.
A very realistic “cardiac catheterization” could be performed in
this environment. 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 can be tested.
The wave of the future is outside report cards. Hospitals will be increasingly expected to report safety data to governmental agencies, payers, and other groups. He said that the public will hold physicians, physician practices, and hospitals more accountable in the future for adhering to best practices of care. For example, the Centers for Medicare and Medicaid Services collects information from hospitals as to how many were appropriately vaccinated for pneumonia and influenza, how many patients got guideline–recommended medications for heart failure, and how many got antibiotics for treating pneumonia in a timely fashion.
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