The Long Road Ahead

Patient safety from a systems perspective

After two weeks of OCY (Orientation to Clinical Year), we’re into our week of “intersession,” which attempts to prepare us for our specific upcoming rotation (medicine, surgery, ob/gyn, etc.) and also to explore topics not covered in the traditional medical curriculum. This week’s intersession theme is patient safety, quite appropriate for us naïve students. So we learned about infection control, scrubbing into surgeries, reporting medical errors and close-calls, and writing appropriate prescriptions to avoid mix-ups. As students, we are in charge of a few patients, including their initial evaluation and treatment plan, which we discuss with the supervising physicians (residents and attendings). Although we are not allowed to prescribe by ourselves, we write out the prescription and have the resident or attending approve and sign the script. Of course, in the hospital, this process is all done on computer, minimizing errors.

The issue of reporting medical errors and near-misses is an interesting one. A patient safety officer who spoke to us mentioned the shifting of procedure from “blame-and-shame” to a critical look at safety systems in place. In the past, an intern prescribing penicillin to a patient with an allergy would suffer a harsh trial by fire, including possible disciplinary action. The current system, at least at Duke, instead looks at the multiple safety checkpoints that failed and why they failed. Why did the computer allow the intern to order the drug despite the allergy? Why did the pharmacy not notice the error? Could there have been extra checks that would have prevented the mistake? And so forth. The essential message was that all humans are fallible, and therefore superior safety requires the use of multiple checkpoints in a system. I say superior safety because even 99.9% accuracy is not good enough. If the airlines accepted 99.9% accuracy, there would be a major plane crash every 3 days. If all the delivery wards in the US accepted 99.9% accuracy, 12 babies would be given to the wrong parents every day. (These figures from the Institute for Healthcare Improvement.) Since humans working in a complex system cannot be expected to consistently maintain such a high standard of accuracy, mistakes and mix-ups must be viewed from a systems perspective, and checks must be in place to provide additional barriers to error.

posted by Ashish @ 11:10 PM