Building a Safer Health System: Reducing Preventable Medical Errors, Lecture notes of Medicine

Download Building a Safer Health System: Reducing Preventable Medical Errors and more Lecture notes Medicine in PDF only on Docsity! editOrials 435 IMAJ • VOL 11 • JULy 2009 to err is Human – But to err repeatedly is….???? Shimon Glick MD Moshe Prywes Center for Medical Education and Immanuel Jakobovits Center for Jewish Medical Ethics, Ben-Gurion University of the Negev, Beer Sheva, Israel by what they consider preventable ill- nesses or complications [5]. In spite of the decade that has passed since the publication of the Institute of Medicine report there is the general feeling that too little has changed from the point of view of reducing the num- ber of preventable deaths [6]. The natural, and virtually instinc- tive, reaction of many administrators, legislators and the media is to identify the individual who was "responsible" for an error and punish him/her in one way or another. Disciplinary actions and malpractice suits are examples of this approach. Unfortunately, there is little evidence that such steps have any signif- icant impact on the overall incidence of medical errors. The title of the Institute of Medicine report clearly reflects its position that the focus should not be on the erring individual, who is usually a competent and careful individual, but rather on the second half of the title – "building a safer health system." Another appealing and relatively sim- ple reaction to an error is the creation of an administrative guideline intended to remedy the perceived problem. Phys- icians faced with a growing array of guidelines and instructions, and already drowning in a flood of paperwork, only occasionally change their daily habits as a result of a new administrative edict. A recent journal article [7], accompanied by a photograph of the pile of guidelines received by a British physician over a short time period, appropriately labeled the collection "Tower of Babel." It has become clear that creating that safer health system is a complicated multidisciplinary task that requires a radical cultural change. A consortium of leaders in the patient safety field [8] t he U.S. Institute of Medicine report [1], a decade ago, on the frequency of preventable deaths in the American health care system sent shock waves throughout society. Many experts in the field believe that the scandalous figures represent an underestimate of the magnitude of the problem. In Israel, Donchin [2] courageously examined prospectively the frequency of poten- tially fatal errors in his own intensive care unit, finding an average of 1.7 errors per patient daily. A recent survey of intensive care units in 27 countries reported 74.5 errors in parenteral drug administration per 100 patient-days [3], and this was criticized [4] as represent- ing significant under-reporting. The growing complexity of medical care, the multiplicity of procedures and medications, the shortening of hospital stays and of time per ambulatory patient visit, the large number of individuals interacting in the care of the patient, and the increasing economic pressures have contributed to the increase in the frequency of dangerous errors in daily patient care. All indications are that the present trends will worsen unless major changes are introduced to stem the tide of medical error. The public too has become much more aware of the problem and is no longer willing to tolerate the uncon- scionable toll of human life and suf- fering, much of which is preventable. Government agencies and insurance companies have begun to consider non- reimbursement for hospital stays caused described the first "quantum leap" in the developing "safety culture" as the limitation of blame. Systems thinking, transparency, accountability and team- work are among the other changes that are required. The anesthesia field has set an exam- ple of dramatic improvement in patient safety over several decades [9] by system- atic examination of their procedures and system-wide changes that made previ- ously common fatal errors almost impos- sible. Two such examples are the ensur- ing uniformity of the direction of knob rotation in all anesthesia machines when regulating the concentration of anes- thetic gases. Another major change was that of changing the connections from the anesthesia machine to the various gas lines so that it became impossible to connect the oxygen line to the anesthetic gas line. These and other similar changes would seem so obvious, but many years passed before they were put into effect. It took considerable media publicity and a major culture change in the field for these changes to be introduced. In another area of endeavor the remov- al of ampules of potassium chloride from resuscitation carts next to ampules of sodium chloride has saved many lives. There are certain errors that have been labeled "never events," those that should never happen. These include wrong site, wrong procedure, and wrong patient operations [10]. Similarly, giving the wrong type of blood is an example of a "never" event. Introduction of detailed procedures to be followed without excep- tion using checklists can virtually elimi- nate such errors, in a manner similar to the kind of checklists used with great success both in the commercial avia- tion industry and in combat aviation. A medical error, quality, patient safety IMAJ 2009;11:435–436 keY wOrds: