A Strong Step for Safety

Maureen Larkin, for HealthLeaders Media, February 14, 2008

In the February edition of HealthLeaders magazine, I write about how some hospitals are learning from the high-profile errors of others and taking steps to make sure that those same errors don't occur at their facilities.

Dan Sheridan, medication safety pharmacist at the Marion (OH) General Hospital, says part of his organization's strategy to prevent medical errors has been an environment where staff members are encouraged to report mistakes.

"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. We strongly encourage people to report errors and thank them for doing so," he says.

This strategy has worked for many hospitals, and now the U.S. Department of Health and Human Services (HHS) is hoping that the establishment of patient safety organizations (PSO) will further encourage doctors and other caregivers to voluntarily report medical mistakes and other dangers to patients' wellbeing. The rule--that would allow the Agency for Healthcare Research and Quality to certify public and private organizations as PSOs--was announced earlier this week.

This is a very big step for healthcare in the United States. It's a way to change the secretive cultures that exist in our hospitals--created by a litigious society that suppresses the ability for physicians and other caregivers to admit mistakes and discuss with others how to prevent future errors.

PSOs will not only confidentially collect information about mistakes, but also work with the erring physician and his or her colleagues to make sure that this particular error is prevented in the future. PSO members will act as "consultants" suggesting changes in routine procedures that can make the hospital a safer place for patients.

The organizations will also make it more likely that physicians and healthcare organizations will collect and report patient safety data--giving the industry a better handle on what errors are occurring and what can be done nationwide to prevent recurrences. Knowing what's happening in the industry and being able to sit down with your own staff to discuss it is important for any hospital's effort to eliminate medical errors.

Take what happened to three newborns at Cedars-Sinai Medical Center in November 2007. The infants received 10 times the recommended dose of the blood thinner herapin--the same exact error that occurred at in September 2006 at Clarian's Methodist Hospital. In my HealthLeaders article, Kurt Patton, former executive director of accreditation services for The Joint Commission (formerly JCAHO) and principal of Patton Healthcare Consulting, LLC, in Glendale, AZ, says keeping track of what's happening in other healthcare organizations and using that information to discuss patient safety with your staff is key.

"I think many hospitals probably are looking at these occurrences in other organizations. 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.

Communication is key to problem solving in any organization and HHS' proposed rule will go a long way in encouraging healthcare providers and organizations to not only share what's going wrong at their hospital, but to talk about it in a way that will prevent future mistakes.

Maureen Larkin is quality editor with HealthLeaders magazine. She can be reached at mlarkin@healthleadersmedia.com.
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