Patient SafetyVince Watts, MD, MPH

Topics

• Patient Safety– Overview– Tools– Emerging issues

• Change– Theories/models of change– How to lead change

Where are we coming from?

“First do no harm”Worthington Hooker, 1849

“…the first requirement of a hospital is that it should do the

sick no harm”Florence Nightingale, 1863

End Results Hospital

• Earnest Codman• 1911-1915• Boston

– Errors due to lack of technical knowledge or skill– Errors due to lack of surgical judgment– Errors due to lack of care or equipment– Errors due to lack of diagnostic skills– The calamities of surgery that are beyond our control

Eli Schimmel• Annuals of Internal Medicine 1964

– Examine iatrogenic harm at Yale University Medical Center

– 1960-1961

– 20% of admissions were injured

– The length of stay was 140% greater in those who were harmed

– 4% severely injured or killed

Jeff Cooper• Biomedical Engineer

• Hired at Mass General to assist with anesthesiology research

• “Preventable anesthesia mishaps: a study of human factors” Anesthesiology 1978

**Led to widespread changes in the field..starting in 1994**

To Err is Human

• Institute of Medicine Report• Medical errors kill more people than breast

cancer or AIDS

Adverse events in healthcare

1 in 20

Ways to Go from National Geographic Magazine 2006

Note: Data for adverse events added to graphic.

Elizabeth McGlynn

• Population based survey• New England Journal 2003• “the average American receives about ½

the most basic routine healthcare”

Safety and Quality

Immediacy

Cau

salit

ySafety

Quality

Where are we now?

Understanding how things go wrong

Patient Safety – Human Error

Technical

IndividualTeam

Profession

InstitutionPolicies/Procedures Accident

LATENT FAILURES

DEFENSES

Incomplete procedures

Regulatory narrowness

Mixed Messages

Production pressures

Responsibility shifting

Inadequate training

Attention Distractions

Clumsy Technology

Deferred Maintenance

Two views of how to improve patient safety

Design, Technology, and Standardization

• Human Factors Engineering• Computerized Support• Standardized Procedures

A surgical safety checklist to reduce morbidity and mortality in a global population.

Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group.

People make safety

• Culture of safety• Training for procedural skills• Teamwork and communication

Association between implementation of a medical team training program and surgical mortality.Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP.

Developing Effective Solutions

Unintended Consequences of “Obvious” Interventions

• Forklift story– Workers getting hit in loading dock

area

– Rusty vehicles painted, alarms turned up

– No decrease in collisions, why?

Patient Safety - Human ErrorProcess Design & Organizational Change

• Process Design– Reduce Reliance on

Memory & Vigilance– Simplify– Standardize– Checklists– Forcing Functions– Eliminate Look and

Sound-alikes

• Organizational– Increase Feedback– Teamwork– Drive Out Fear– Leadership

Commitment– Improve Direct

Communication

Why are we here today?

IOM GoalsCrossing The Quality Chasm

• Safe

• Timely

• Efficient

• Effective

• Equitable

• Patient-Centered

Patient care (compassionate, appropriate, effective)

Medical knowledge (biomedical, clinical, cognate sciences, and their application) Practice-based learning and improvement (investigation and evaluation, appraisal and assimilation of evidence)

Interpersonal and communication skills (effective information exchange, teaming with patients and families)

Professionalism (carrying out professional responsibilities, ethics, sensitivity)

Systems-based practice (awareness and responsiveness to larger context and system of health care, use of system resources)

Berwick “lessons”

• Error is not the problem, harm is the problem• Rules don’t create safety, rules and breaking

rules creates safety• We don’t have reporting to measure

progress, we have reporting to understand stories

• Communication (not technology) is mainstay of safety

Berwick “lessons”

• Healthcare is different from other industries

• What happens after an injury is as important as what happens before the injury

QUESTIONS?