Improving Quality and Patient Safety

Three experts on medical safety offered their views on how hospital safety can be improved during the CIMIT Forum on Oct. 30 at the Simulation and Skills Center at Beth Israel Deaconess Medical Center.

Presenting were Ronald Newbower, PhD, strategic director and chief technology officer of CIMIT; Gregg S. Meyer, MD, MSc, senior vice president for quality and safety at Massachusetts General Hospital/MGPO; and Jeffrey Cooper, PhD, director, biomedical engineering, Partners HealthCare System, professor of anesthesia, Harvard Medical School; Department of Anesthesia and Critical Care, MGH.

At the heart of their discussion was the troubling statistic that in one recent year, up to 98,000 patients died in U.S. hospitals as the result of mistakes, some by receiving the wrong medication or an inappropriate dose of the right medicine.

Dr. Cooper spoke on the topic of “New Hazards of Medical Technology: Two Case Discussions.” He said that different systems in hospitals often don’t talk to each other. He outlined several real-life examples where patient safety was endangered because different computer systems were not combining to produce correct and essential information.

He urged listeners to make careful studies in operating rooms and special-care units when changes are made in hospital systems. The slightest differences in health-care operations can cause problems that can take months to correct.

Dr. Meyer spoke about “An Untapped Role for Patients: Online Reconciliation of Meds and Monitoring of Health Care Transitions.”

He said that consumers and medical professionals must continue to ask questions and seek improvements if medical centers are going to increase their safety records.

“I sometimes think of a giant private company like Home Depot,” said Dr. Meyer. “They try very hard to correct problems, and they’ve taken on a culture of improvement. Everyone works to make their store a better operation, and the other stores nationally.
           
“It might take time to implement the correct procedures or ensure that a discharged patient is leaving with the correct medications, but it is really worth it, for hospital and patient.”

Dr. Newbower spoke on the topic of “How to Protect Oneself from Injury by Human Error.”

Every year, 100,000 people die in United States hospitals because of preventable human error, making this the eighth leading cause of death in the nation.  According to a 1999 report entitled To Err is Human, released by the Institute of Medicine, most of these deaths are the result of systemic, not individual, error.  Problems include diagnostic errors, treatment mistakes, inadequate patient monitoring, and outright equipment failures.  Patients can protect themselves by maintaining their visibility and by understanding the risks that they face in the hospital.

People should not go to the hospital needlessly and should seek a second opinion before electing to undergo non-emergency surgery.  When in the hospital, one should attempt to have an advocate with him or her.  The advocate should be someone who can ask questions that the patient may be too sick or too shy to ask for him or herself.  Patients must remember that they have a right to know the details of how they are being treated.

The riskiest moments for a patient occur during handoffs, when the patient is passed from one caregiver to another, as doctors and nurses new to one’s case can make mistakes.  Infections are also a hazard, for drug-resistant bacteria lurk in hospitals.  A study conducted by the New England Journal of Medicine showed that simple sanitary practices, such as regular hand washing, can reduce infection rates to almost zero.  Thanks to ongoing technical and educational progress, patient safety is improving, but work remains to be done.

   

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