Medical errors are estimated to be the third leading cause of death in America. This is worth repeating – the THIRD leading cause of death in this sophisticated, educated, economic power house of a country is mistakes, errors, mishaps…
Why aren’t we outraged? Why aren’t we paying more attention?
I understand that healthcare, as a “system”, is a complicated, ever changing industry that relies on fallible human beings to work well in complex, difficult to repeat situations each and every day. But, here’s the reality – healthcare is NOT alone! There are industries equally as risk-filled with far better safety records! Why is it that the same level of safety we demand for our automobiles or airline travel is not demanded to protect a life, our’s or a loved one’s, when we enter a hospital?
There are many industries, other than healthcare, that work in complex environments where the actions of one human can impact the life of another. Healthcare leaders need to acknowledge the reality that we have much to learn from other industries. While we cannot mimic others entirely, the same general operating principles (including mindfulness that serves as the overarching organizational spirit) that are the foundation for other high reliability organizations (i.e.: aviation, nuclear power) can work just as well to prevent harm from occurring in health systems.
One example of a safe practice or technology that could shared across industries is the in-flight data recorder found on all commercial airliners. It was because of the in-flight data recorder on board the two Boeing 747s that crashed into one another on the island of Tenerife in 1977 that we learned so much about the decisions and behaviors resulting in that game-changing airline disaster. The time stamped voice commands of those at the controls were captured in real-time, and provided a blueprint of what “not to do” along with a snapshot of what needed to be changed.
Now envision this: following a surgical procedure, regardless of the outcome, we have the opportunity to review every piece of data related to the procedure.
We currently have the technology by which we can go back and look at thousands of time stamped data points to review and/or recreate events as they transpired in the operating room. We can capture voice, video, blood pressure, oxygen levels, numbers of plasma/blood transfusions. The data would stream from the medical equipment in the room, from the microphones, the cameras, and any other sources that we choose to capture, into a device that allows playback, review and re-enactment.
We could assess team work, learn from the practice of those at the top of their game, and use this data to improve. We could revisit poor outcomes and learn what should be done differently in similar circumstances. This is not a pipe-dream, nor is it my idea; it has been developed and is currently being used and piloted by Dr. Teodor Grantcharov, a general surgeon at St. Michael’s Hospital in Toronto, Canada.
An innovator if ever there was one.
The choice to innovate is not, in fact, a choice – it’s an imperative.
I firmly believe we have the expertise, the intelligence, the resources, and the creativity to make healthcare less costly, more effective, more patient centered, and far better. We need to give ourselves the permission to try, to innovate, to disrupt our environments in ways that lead to safer, more effective and more humane healing environments.
This effort is long overdue and new rosary to protectboth surgeons and patients. We need to learn from our mistakes as well as weed out the body among so many good. There is great learning and technological gains that can conman from this but I fear the medical practitioners lobby will fight it to the and nail because they would no longer be self regulated in addition to ambulance chasing lawyers.
I believe that the number of medical errors will drop dramatically if one action is taken by everyone who can possibly do so. That action is the mantra “never alone”. My vision for the future is: If you or a family member is hospitalized a phone tree is activated so that every hour of that hospital stay is covered by a person sitting next to you. They hear the instructions, they hear the interaction with the patient, they support the nurse in exact ways they are instructed. Even if it is to have reading material, a deck of cards, an iPhone to play games on, their job is presence and care. Personal accountability as a patient has to mean that we have our 100% and the healthcare provider has their 100%. It’s not an adversarial post to “stand watch” it is a supportive one that is needed and necessary. As in a court of law,” if you don’t have or can’t afford representation, someone will be appointed for you”. The mess in healthcare can be a job creator! 100% support person(s) for every patient. Someone who can read, write, and keep the “care book” in plain terms one supporter to the next. I have come to see that with all the stresses, strains and requirements heaped on providers in hospitals anything except a trained army of “NA’s” – Never Alone is going to improve things. Hospitals can offer NA (Never Alone) classes (along the lines of Emergency Preparedness) — how to sit and watch; how to write things down; how and when to speak to the provider if needed (which should be rare). Providers deserve a ridiculous amount of support, and would be well advised to train anyone or family unit willing to support them. Heaven knows volunteers at hospitals can be a force for greater good beyond walking people to locations and tending the gift shop. A chair beside every hospital bed to listen, learn and support. Boring? Maybe — but so are those long, long flights for pilots. Someone has to do it.
It’s important to think about what is motivational to cause busy clinicians to spend time and effort on clinical process improvement. The tack often taken, applying financial metrics and/or revised payment methodologies, is destructive on that front.
Excellent train of thought. Let’s keep in mind that many of the data streams to recreate “what happened” exist and there are few simple data points (who touched the patient, for how long and where) that are missing. These can be collected with simple technologies that exist today. In other words, taking incremental steps to improve is not that hard as long as we don’t burden clinical staff with additional steps merely for the sake of collecting data that may have an impact in the future.