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Patient Safety: Key Healthcare Insights


The Global Patient Safety Forum is hosting a Patient Safety and High Performance Leadership Summit to discuss the issue this Friday, April 27, 2012. Leaders from across healthcare, government agencies and other stakeholder groups are gathering to address patient safety and high performance leadership – with a special focus on healthcare information technologies.

The program will be broadcast live online from 10 a.m. to 3 p.m. US Eastern Time. You can also follow the patient safety conversation on Twitter throughout the day Friday, April 27, using the hashtag #HITTMIT.

The Patient Safety Summit will focus on several topics, including:

– Government programs such as the Partnership for Patients, the Agency for Healthcare Research and Quality (AHRQ), and Quality Improvement Organization.

– Recent Institute of Medicine HIT and Patient Safety Report.

–  Proposal of an NTSB for healthcare.

– Other issues related to hospital leadership, governance, and safety, including leadership training and the unique needs of both safety net and rural hospitals.

The documentary “Surfing the Healthcare Tsunami: Bring Your Best Board™” will also be premiered that evening (Friday, April 27, 2012) for national leaders and the public. Click here for details.

As rising costs, big data and democratization frame the evolution of healthcare globally, healthcare providers and professionals are under increasing pressure to offer high quality care that is both low cost and safe: free of errors, re-admittances and other safety issues.

Healthcare professionals, such as Dr. Mark Chassin, president of the Joint Commission, have talked about the difference between human mistakes and medical errors due to  a failure in the hospital’s system during the ‘Hospital Performance and Patient Safety in the 21st Century’ congress in 2010.  “We’ve heard a lot about how a safety culture is really a blame-free culture—well, high reliability organizations are not blame-free cultures. What they have is a way of separating the kinds of mistakes that everybody makes every day because we’re human that we should be learning from.” Dr. Chassin clarified, separating them “from the other behaviors or mistakes that are so egregious that if you don’t deal with them with disciplinary action you lose the trust of all the caregivers and the organization.”

Dr. Chassin also talked about negligence in cleanliness, citing the example of a housekeeper that might think that just because he/she does not have direct contact with the patient that hand-washing is not necessary; touching things in the different rooms and spreading germs in vulnerable patients’ environments. This is a frequent occurrence, and shows a gap in training in some hospitals.

The issues to work on differ from one hospital to another according to Dr. Chassin, who also said that hospitals won’t be able to improve their cleanliness habits if they don’t know what they have to work on. He also pointed out that the solutions to the problems in one hospital may not be applicable to others – the measures must be made in each hospital separately. The start of any healthcare change must be in the hospitals themselves.

Dr. Hal Kaplan, Professor of Health Evidence and Policy at the Mt. Sinai School of Medicine, talked about the utility of the analysis of near-misses during the same congress, enabling organizations to work proactively to prevent medical errors. He noted "to have (medical) event reporting be as effective as it ought to be, we need both trust and motivation." The key to improving medical event reporting according to Dr. Kaplan is to have both a reporting system and a culture of safety. "We don't yet have a good handle on using this data for actionable knowledge," he concluded, "but we're moving forward."

The Inspiration for a New Healthcare Information System

The inspiration for a new way of thinking about patient safety could come from looking outside the healthcare spectrum and into other high stress sectors that have already made marked improvements. One example is the Aviation Safety Reporting System, a tool that provides information from pilots and cabin crew and near-miss events voluntarily to NASA, who gathers the data to study and improve safety. This is one of the reasons why air travel has become so much safer.

A similar system could work inside healthcare; if professionals voluntarily reported near-misses without fear of consequences, there would be greater advances in the prevention of healthcare errors and a betterment of patient care. Patient Safety Organizations (PSOs) offer another opportunity for healthcare systems to better understand their current and trending safety data and allows them to benchmark against their peers.  Creating a culture of safety and gaining the ability to understand and apply data were both critical pieces in the aviation industry’s safety efforts that helped move them forward.

Mayo clinic was one of the pioneer healthcare institutions that began to gain inspiration from other sectors. The Mayo Clinic team brought a NASCAR pit crew chief to look at their operating room turnover. “They are very focused on safety and efficiency and speed of turnaround similar to our ORs,” says Bob Bigham, COO at Mayo Clinic in Florida during an interview on a TMIT documentary. “We brought a pair of fresh eyes to see the operating procedures and turnover time and got great suggestions. I think these are observations that we might not have seen.”

Will Healthcare Learn?

The creation of Patient Safety Organizations (PSOs) by the Agency for Healthcare Research and Quality (AHRQ) is the first step towards the voluntary sharing of information needed in the Healthcare sector and, if embraced, will improve the ability to make lasting patient safety changes.  

In February 2011, the Secretary of Health and Human Services (HHS) listed the GE Patient Safety Organization (GE PSO) as part of the AHRQs PSO program. The GE PSO provides its members a single common medical event reporting platform, with comprehensive data analytics and advisory support to identify the root causes of risk, and help hospitals make lasting safety improvements. With members across the country, the GE PSO is helping healthcare systems in the US address some of their toughest patient safety concerns.