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Department Focus: Quality--Are We Learning from Our Mistakes?

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When a critical error occurs at another hospital, leaders must escape the 'it won't happen here' mentality.

The September 2006 deaths of three infants who received overdoses of the blood thinner heparin at Clarian Health's Methodist Hospital in Indianapolis generated national attention in the medical community. With such a brutal reminder of the importance of patient safety processes, surely such a mistake could not happen again.

But it did. In November 2007, three infants received heparin overdoses at Cedars Sinai Medical Center in Los Angeles. The errors in this case were not fatal, but public backlash was swift, nevertheless, as many in the community wondered, "How could this happen again? Didn't they learn from what happened in Indianapolis?"

Learning from other facilities' mistakes can be a tougher challenge than it might seem. In many cases, hospitals may be operating under a false sense of security, says Michael R. Cohen, president of the Institute for Safe Medication Practices. "People think a lot of these things can't happen to them, and then they happen," he says. Cohen's organization publishes a biweekly newsletter that discusses medication errors and ways for hospitals to avoid them. "But if you look at all these rare errors where people are killed, it seems like it's the same ones repeating themselves," he says. "You begin to recognize the same drugs, the same situations."

Kurt Patton, former executive director of accreditation services for The Joint Commission and principal of Patton Healthcare Consulting, LLC, in Glendale, AZ, contends that the Cedars Sinai incident notwithstanding, many hospitals are learning from others' mistakes. "When you hear about something like this, you bring the information to your staff meeting and ask, 'How vulnerable are we?' and 'What can we do to prevent it happening here?'" he says.

Still, discussing errors during a staff meeting may not be enough. Patton acknowledges that hospitals such as Cedars Sinai are the victim of an industry culture of glacial action. "We talk constantly about reducing risk, but we need to talk about eliminating it," he says.

As with many cultural shifts in the hospital, the involvement of hospital administrators is crucial, Cohen says. "You need to work on not just internal errors, but those that have happened elsewhere. You need to make the staff understand that you're really serious about this effort . It starts at the top."

Long before the heparin overdose at Clarian in 2006, Marion (OH) General Hospital started a Medication Safety Team in 2000 composed of nurses, pharmacists and other hospital employees. The organization's vice president for medical staff affairs is a member of the team, emphasizing the administration's commitment to an error-free medical environment.

The team meets regularly to discuss medical errors that have occurred at the hospital as well as errors at other facilities, says Dan Sheridan, medication safety pharmacist at the 147-staffed-bed hospital. "We develop strategies to try to prevent a recurrence. We know that if it happened at another hospital, it could happen to us, too."

One of the Medication Safety Team's recommendations was for Sheridan to sit down with the hospital's neonatologist and the nurse clinician who works in the nursery to evaluate "every drug we stock in the nursery and every drug that was on the crash cart in the nursery," Sheridan says. "We ended up completely removing heparin from the nursery and pulled eight to 10 other drugs that were potentially risky."

The team has not only taken actions that will eliminate risk, but it has also proven to be an inexpensive and effective way to change the culture of the hospital, Sheridan says. "When we first started the team, there were many who had a punitive approach, but the mindset has shifted with time. If people think that they're going to be punished when they report an error, they won't report the error, and then we can't prevent it," he says. "We strongly encourage people to report errors and thank them for doing so."

-Maureen Larkin

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