The patient safety movement has come to "a little bit of a standstill," said Jefferson Health leader Oren Guttman, MD.
Dr. Guttman, Jefferson's enterprise leader in safety and high reliability, joined the AHA's Advancing Health podcast to discuss patient safety efforts since the groundbreaking report, "To Err Is Human: Building a Safer Health System," was published in 1999.
Healthcare is an irreducibly complex system, Dr. Guttman said on the podcast, because "the same events that interact today and produce success can interact tomorrow and produce failure."
When the report was published, about 10% of health systems used an EHR. Now, EHRs and other technology are everywhere in the industry. This is the disconnect, Dr. Guttman said: Patient safety efforts have focused too heavily on the human contribution to safety and have largely ignored how technology affects safety.
Another pitfall is the goal of healthcare facilities becoming high reliability organizations, he said. High reliability studies are based on industries with more knowable inputs than healthcare.
Instead of trying to "error proof a process," where errors happen all the time, Dr. Guttman said, "better organizations are able to detect those errors, and they're able to rescue those errors from turning into failure."
This concept is an idea from resiliency engineering, which constantly searches for errors and attempts to prevent errors from becoming failures.
One way Jefferson Health adapted this concept is by changing its Great Catch award. Historically, the award would be bestowed to employees who prevent harm. Now, the system awards employees who report a broken technology, tool or process, which is an upstream view on system failures.
Another strategy leans on training resiliency.
Dr. Guttman's example: "What's really important in training, classically, is we've taught it from an error-avoidance perspective, 'here's how you do this correctly.' What's super important is, in all of our training modules, a resiliency approach would invite us to include at every step how that step could fail and include that in the actual training. Because by priming people and helping them understand the errors that could lead to failure, and then also teaching them how you rescue the error from the coming failure, you make that process more resilient."