Lessons on Patient Safety

We had a great turnout this morning for UH Parma’s Quality and Patient Experience Conference.  A number of doctors and nurses, Board members, residents and medical students, as well as a number of members of the hospital and UH administration.

One big initiative at University Hospitals (and throughout the country) is to take a close look at patient safety.  Medical errors are a huge problem and the subject of intense scrutiny.  Because people are human and medicine is a human endeavor, it has been thought for a long time that medical errors are not entirely preventable.  Lately the thinking has shifted to an opinion that by building systems that include layers of checkpoints to catch mistakes, it is possible (and necessary) to prevent medical errors.

There was a lot of discussion today about how keeping patients safe while treating them will be taken into account when determining payment for medical treatment.  Doesn’t that make sense?  All else being equal, those doctors and hospitals that have excellent patient safety records should be rewarded.

I had 3 big takeaways about patient safety from today’s conference that I wanted to share with you.

Everyone’s responsibility

The first point was that patient safety is EVERYONE’S responsibility.  From the doctors and nurses to the dietary staff to the custodians, everyone contributes to safety and any person who notices a problem has a responsibility to speak up.  We also have a responsibility to listen to each other if there is a patient safety concern.

It’s important to realize that patient safety also relies on the patient.  If you or a family member is seeing the doctor or in the hospital and something doesn’t seem right, it is your responsibility to speak up, ask questions, and clarify the situation.  The days of thinking the doctor is always right and trusting that the medical system knows best are definitely over.

Make sure your team knows your medications, ALL your history, your habits and preferences.  Don’t assume something is unimportant.  If you had surgery when you were 3 years old, include it on your history.  If you are a recovering alcoholic and sober for 20 years, include it on your history.  (And you rock, by the way!)  If you’re SUPPOSED to be taking thyroid medicine but ran out a month ago and haven’t got around to getting it refilled, let us know that.

Building systems and checklists

Medicine is often compared to the airline industry in terms of complexity and the level of risk.  Makes sense, right?  If an airline mechanic screws up the plane might crash.  If a pilot makes a bad decision the plane might crash.  Many, many people have to do their job right to match a safe landing to every takeoff.

This comparison isn’t perfect.  After all, when was the last time a 747 decided to do a barrel roll during a nice orderly landing?  Airplanes can’t decide not to take their medications or eat food that’s not good for them!

However, what pilot would think of taking off without going through the preflight checklist?  There are procedures for speaking with the control tower, taxiing, takeoff, routing, landings, etc.  Everything is planned and done the same way every time.

That’s an advantage that medicine is really starting to understand.  We’re beginning to have protocols and checklists, standard order sets and procedures that are done the same way every time.  Training staff on these patient care procedures and providing doctors with proven treatment algorithms makes sure things are done right the first time and important steps aren’t missed.  Taking advantage of things our technology does easily, like setting alarms if a patient has a fever or her weight changes drastically, adds an extra layer of safety.

Happy patients are safer

I was surprised to see data suggesting that patient satisfaction data correlated somewhat with patient outcomes.  For instance, patients that were happier with their care were less likely to have problems with their care like being readmitted to the hospital soon after going home.

There isn’t an obvious or easy explanation for this correlation.  Since some of the patient satisfaction measurements involve how well the doctors and staff communicated with patients, patients who understand their care and their treatment plan better may be more likely to do well after going home.

We have a lot of work to do as an industry to continuously improve patient safety.  Errors are NOT to be accepted as part of the cost of doing business.

QUESTION:  Have you or a family member been affected by a medical error?


One thought on “Lessons on Patient Safety

  1. Yes. My 88 year old healthy mom all of a sudden suffered from acute back pain. Her physician said it was just her old compression fractures & prescribed Forteo injections, pain pills, that didn’t work, & inflammation pills. 3 weeks before this I questioned the nurse on my mom’s calcium number & her 10 lb. weight loss. I was rudely told the calcium with within guidelines & that they were watching her weight. After 6 days of fighting the pain, I called & refused to bring her into the office & told them I thought her spinal cord was involved & I wanted approval to go to ER. 3 hours later I was told to take her to the large hospital in Fort Worth. The ER physician said she aced the exam. I then questioned why if her grip was strong could she not hold the weight of a Styrofoam cup. At that point he ordered several tests. That same day she was diagnosed with kidney cancer that had spread to her bones & she had only weeks to live. I get angry when I think of the 6 days she suffered & that it took my determination & gut instinct to get her any relief. I feel sad for the people that don’t have an advocate on their side.

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