This weekend I had the pleasure to attend to the Patient Safety Movement's Patient Safety, Science & Technology Summit. The Patient Safety Movement is a grassroots movement that seeks to get to zero preventable deaths by medical errors by 2020.
I served as a panelist on Saturday, discussing the media's role in improving patient safety, and stayed through Monday attending sessions and learning about the movement's efforts to reduce preventable harm.
More than 200,000 patients die each year due to preventable harm; millions are injured (some studies would suggest 5 million-9 million patients are harmed each year in American hospitals.
Approximately 1.7 million healthcare-associa
ted infections occur each year, wrong site surgery occurs 50 times per week, and hand off communications fail 50-60 percent of the time. Adverse drug events result in more than 770,000 injuries and deaths each year.
These statistics are harrowing and represent a major failure of American healthcare.
To be sure, hospitals across the country have been attempting to improve patient safety culture for more than a decade. The 1999 Institute of Medicine "To Err is Human" report was the first report to bring the prevalence of preventable error to light, and encouraged hospitals to make changes to prevent harm. Yet, more than 15 years later, the needle has not moved.
Why?
Joshua Adler, MD, CMO at the UCSF Medical Center has an idea. "Most of what we've done in safety has focused on tools and processes," he said. Tools and process, however, can easily fail.
For one, they are susceptible to work-arounds if the culture does not support them.
Second, the reasons hospitals fail at intervention — for example achieving 100 percent compliance for hand hygiene, or requiring two employees to verify medications before administration — vary by hospital. Therefore, an intervention that targets one root cause could be very successful in one organization but bring only small improvements in another.
"The harder you look, the more causes of the problem you find," explained Keynote Speaker Sir Liam Donaldson, the World Health Organization's envoy for patient safety, adding that each cause requires a different intervention.
Getting to zero
Healthcare organization across the country continue to employ traditional tool- and process-based interventions; yet, preventable harm continues to occur.
What must be changed?
Apparently, a lot. "We need a different way to do improvement if we are going to get to zero," said Mark Chassin, MD, president of The Joint Commission.
According to many speakers at the summit, organizational culture must change. Safety must be a guiding force. If this happens, employees are comfortable voicing concerns, and work-arounds are avoided at all costs.
Healthcare organizations must become high reliability organizations, said Sir Donaldson. One characteristic of HROs is having a strong response to weak signals, something Sir Donaldson says healthcare largely lacks. For example, while most hospitals investigate reported patient harm, most don't take near misses — a type of weak signal — quite as seriously.
Organizations must create a culture that investigates near misses and is committed to changing problems they uncover. According to Sir Donaldson, the five most dangerous words in healthcare are, "It could not happen here.”
The Patient Safety Movement is moving toward its goal of zero preventable deaths by 2020 through a variety of initiatives. One is encouraging hospitals to make commitments to take on a patient safety improvement project and report results with the organization. Of hospitals committing in 2013, their efforts led to 602 lives saved. The Patient Safety Movement hopes to sign on additional hospitals in 2014.
To learn more, visit: http://patientsafetymovement.org/commitments/