24 Sep Since to Err Is Still Human, Healthcare Could Use a Little Help
Mimi shares how embracing new processes, tools, and approaches – including a National Patient Safety Board – could dramatically reduce hundreds of thousands of lives lost each year when harm IS done in the hospital.
Since to Err Is Still Human, Healthcare Could Use a Little Help
Hi, I’m Mimi Grant, of the ABL Organization.
Can you remember back to just before the “turn of the millennium”?
Technology, like the Internet, was beginning to change everything – including healthcare, with life-saving drugs and medical procedures.
Yet, in 1999, the Institute of Medicine’s released
“To Err is Human.” The nation was shocked to learn that 98,000 patients die in the hospital at the hands of “the system” each year.
Since then, Johns Hopkins has released a steady stream of reports, like “preventable medical errors cause an estimated 251,000 deaths a year in the U.S.,” ranking them as “the third-leading cause of death.
And some researchers have claimed the number of preventable deaths could be as high as 440,000, because “physicians, funeral directors, coroners and medical examiners rarely note on death certificates the human errors and system failures involved” in patients’ deaths.
So now there’s a proposal for a National Patient Safety Board modeled after the National Transportation Safety Board.
Like the NTSB, the NPSB would be an independent federal agency, to “conduct centralized studies into medical mishaps and systemic breakdowns to prevent future catastrophes.”
Now that EMRs are nearly universal in hospitals, the idea would be to use de-identified data from these health records, artificial intelligence, and reporting from other agencies, to identify cause-and-effect relationships and issue timely recommendations to improve patient safety – for everyone.
Fortunately, since To Err is Human was published, several steps have been taken to dramatically reduce the number – and likelihood of medical errors.
For example, The Leapfrog Group, has reported on the harm done to mothers and babies by electing a pre-term delivery date – a cause that the March of Dimes actively advocates against.
The result has been a reduction of early elective delivery rates by 84%.
And Dr. Atul Gawande’s book The Checklist Manifesto: How to Get Things Right, was published ten years after To Err is Human.
This path-breaker related data and lessons learned from the airline and other industries, including the value of implementing the World Health Organization’s pre-surgical checklist.
When discussing the WHO Checklist with the ABL Organization’s San Francisco Healthcare Round Table, several Members recounted the pushback they’ve experienced, particularly by surgeons, with applying this simple and effective approach of reviewing a pre-surgical checklist for improving the quality and outcomes of care.
The bottom line is, sharing responsibility in the OR – and making time to listen again and again thoughtfully to the same questions on the checklist, requires massive culture change.
Another example of how healthcare is getting safer, is Kaiser Permanente’s Garfield Innovation Center.
There, they test not just products but alternative approaches to better, safer care.
For example, on an airplane it would be a rare event indeed if someone outside the cockpit – like a flight attendant – actually put a passenger in harm’s way.
But, in healthcare, it happens every day: a pharm tech mislabels a drug, and a nurse administers it without question.//
At the Garfield Center they modeled how nurses could easily confuse the meds intended for Mrs. Jones in bed 221A with Mrs. Black’s, in 221B, if they were distracted.
These medication mix-ups are the second most frequent medical error, after misdiagnosis.
Through repeated trial-and-error simulations, clinicians at the Center devised a simple, but effective way to greatly reduce medication errors – it’s called KP MedRite, a 3-step Consistent Protocol to prepare and administer meds, which includes “no interruption wear” – a sash or vest to wear while preparing and administering drugs that signals “DO NOT INTERRUPT.”
And they operate in “sacred zones” where nurses prepare the meds.
More recently, it’s been recognized that particularly new nurses and Travelers, unfamiliar with their hospital’s standard protocols and procedures, need a way to learn them, “Just-in-Time,” from best practice video lessons delivered on the nurses’ smartphones.
For example, Elemeno Health’s on-demand micro-learning solution keeps clinical staff and Travelers up to date on current, data-based and hospital-specific best practices to reduce variation in care.
That way, rather than tip sheets and guidelines getting lost in the Nurses’ Station, guidelines are “in hand” the moment they’re needed.
In the finish, the biggest challenge in healthcare is recognizing that everyone is in a position to “do harm.”
And therefore, processes and tools must be developed and embraced – including a federal agency, to ensure patient safety.
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