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 HealthLeadersarticle, 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.
Freya Gilbert is the director of quality and clinical practice at Hughston Orthopedic Hospital, recently promoted from the position of operating room analyst. That means she is responsible for finding ways to improve hospital quality and performance, which, in turn, can improve patient safety and outcomes. Gilbert took some time out to tell the Ledger-Enquirer about what her title exactly entails, how she moved up the ladder in health care and her experience teaching surgical nursing in Tbilisi, Georgia.
Doctors and insurance companies have something new to fight over: physician rating systems. The major health plans have started rating doctors to show patients whether they're cost-efficient, and physicians complain that numbers don't tell the whole story. The insurers are scrutinizing bills submitted to them without talking to the doctor about the cases involved. Doctors also say they're downgraded when patients don't comply with orders or when an insurer makes a clerical error.
A study by Boston researchers has found that doctors dealing with depression often put patients at risk. Depressed physicians were more likely to report poor health, be working in an impaired condition, and have difficulty concentrating at work, the study says, making it more likely for them to incorrectly order prescription drugs.
Two Ohio hospitals are using new technology to screen patients for MRSA. The new technology can diagnose the infection within two hours--allowing caregivers to treat affected patients faster and squash the infection's ability to spread.
The Agency for Healthcare Research and Quality has launched a campaign to encourage patients to communicate with physicians about their health. The campaign includes a five-minute video that shows how patient involvement can reduce medical errors and improve patient outcomes.
A California lawmaker has introduced legislation that would require health insurers to get permission from state regulators before retroactively canceling a member's coverage. Assemblyman Hector De La Torre said his bill would "protect the rights of insured Californians against unfair practices of insurance companies."
A growing amount of research is investigating whether small cultural differences could be a big reason for the nation's persistent healthcare disparities. In 2005, New Jersey became the first state to require cultural-competence education for physicians to get licenses. The federal government is now financing studies to examine whether the training can help healthcare workers get diverse groups to comply better with doctors' orders.
Facing a deficit, Los Angeles County healthcare officials have unveiled a cost-cutting plan that calls for closing all but one of the county's dozen clinics and reduces services at its six comprehensive outpatient health centers. The proposal would dramatically retreat from the county's longtime role in providing primary care to the indigent. The clinics and comprehensive centers get about 400,000 primary care visits a year, nearly two-thirds from uninsured patients.
A study by researchers at the M.D. Anderson Cancer Center and the University of Texas has found breast cancer information was inaccurate or misleading on 5 percent of the 343 Web sites examined. Also, sites that focused on alternative or complementary medical approaches were 15 times more likely to contain problematic information, according to the report.
