Friday, May 4, 2007

Patient Safety - Our New Focus

I attended a conference today that dealt with a good trend that is sweeping U.S. Healthcare- called the Patient Safety movement. The Institute of Medicine published a shocking report in 1999 that showed as many as 98,000 people die from serious hospital medical errors each year. It is the equivalent of a full jumbo jet crashing each day! That made everyone sit up and take notice and started us looking at how we deliver care. Believe it or not, prior to that report, we never discussed how to change our hospital systems to avoid medical errors and make sure we didn't inadvertently hurt a patient. Health professionals had a mindset that this was just the unavoidable collateral damage of the high-tech, lifesaving war we were fighting against disease.

We now know that way of thinking is unacceptable and we need to collectively change our systems of care so that no patient is given the wrong drug, or the wrong blood or organ, or operated on the wrong side, or given the wrong test, or receives the wrong treatment. Caregivers want to do the right thing for every patient, but the complexities and fragmentation of care are working against us. In the 1950's and 60's, an Internist needed to know about a handful of medications...penicillin, lasix and thyroid pills just about covered the bases. Now a General Internist actively uses over 400 medications, each with their own interactions.

Medicine grew up as a cottage industry, with each doctor running his/her own show and with extreme variations in how medicine was practiced. Whether you get a treatment or not depends as much on where the doctor trained or in what part of the county he practices as much as anything else. These variations in care are part of the problem. You wouldn't get on an airplane if each pilot wanted the cockpit panel arranged his "own way". Why should something as complicated as surgery be any different? As a patient, we deserve proven technology, delivered in a consistent way. There is nothing wrong with innovation, but if there is proof that raising the head of the bed keeps me from getting pneumonia, damn it, I want the head of the bed raised! (yes, it does)

Fortunately the Patient Centered Safety movement is teaching us all how to ensure a patient receives no harm from our actions. It is a cultural change in how we think about patient care. It requires institutions, physicians and nurses to work together as a team. It also requires us to be brutally honest as a profession, to look at each problem we identify and to use a
"systems" approach to redesigning what we do. We need to make it easy for caregivers to do the right thing (barcoding medications, electronic prescription ordering, protocols for "hand offs" of patients) and we need to be willing to tap our colleagues on the shoulder and say "Hey, shouldn't you wash your hands?"


gotelgirl said...

Toni, if all medical professionals were as open to change for the sake of improvement as you are, we may not have the enormity of "a jumbo jet crashing every day" on our hands. Thank you for acknowledging so openly our problems, and being willing to be part of the answer. Your spirit gives me hope!

Toni Brayer MD said...

Thanks for your words, gotelgirl. There are thousands of us out here working to improve what we do and how we do it daily.

LovelyL said...

Timely article especially in light of the recent Pete Wilson loss !


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