In general parlance, a best practice is a method or process which is more capable of delivering desired outcomes. Best practices signify the most efficient and effective ways of accomplishing a particular task — in our context, patient safety. For more than a decade now, people and institutions advocating patient safety have been putting efforts to identify best practices within the healthcare setting. Half of the problem of ensuring patient safety lies in evolving better ways to encourage error reporting.
In order to devise better error reporting methodologies in the health industry, investigators have examined the Aviation Safety Reporting System, which is voluntary effort that is thought to have significantly reduced the risk of death in domestic jet flight over the past few decades. This is a confidential system and its focus is on reporting near misses and violations, i. e. , instances which could have led to accidents but did not and instances which can be clearly seen as violations of established safety practices though they may not have led to an adverse event.
Each report is carefully scrutinized for root causes and the conclusions drawn from in terms of recommendations are shared with the general aviation community. The secret of success of this system is that it does not punish pilot and crew members who report duly and honestly. The simplicity of the system is an added advantage. Expert feedback is provided directly to the crew members reporting the incident so that they can learn something immediately from their mistakes and would be encouraged to report incidents in the future as and when they arise.
There are many high-risk industries such as nuclear power and petrochemical processing where similar systems to facilitate prompt reporting have been implemented. The focus is not just on reporting errors but also any potential errors. This is a proactive method. It has been found out that the patterns among causes are very similar between actual incidents and potential incidents, with minor factors determining whether or not the potential incident actually leads to an adverse event.
In general, successful reporting systems in any high-risk industry should have the following characteristics: 1) nonpunitive 2) confidential 3) expert feedback 4) timely feedback 5) system oriented 6) responsible and responsive — that is, the organization in which the errors or near misses took place candidly admits to them and disseminates the recommendations industry-wide. The existing JCAHO framework for reporting errors and close calls as a part of the RCA methodology incorporates these features.
But thousands of medical errors happen all over the country every week, and if we take close calls into account their number may run into tens of thousands. The JCAHO with its limited staff and resources cannot possibly oversee all these events. Accreditation by JCAHO is only a minimum requirement, the hospitals of the nation have to strive to evolve more effective RCA methodologies for themselves and continually improve their system in order to enhance the levels of patient safety.
Since the IOM report of 1999, a number of hospitals in the country have put efforts in the direction of developing better reporting systems for errors and near-misses (Level I). For example, Valley Hospital in Ridgewood, NJ, has several years ago taken a good initiative to encourage reporting of Level I errors. 80% of all error reports are likely to be these near misses. Valley Hospital’s system covers all kind of possible errors that could happen in a hospital setting, major as well as minor.
It is particularly important to take minor errors into account as some of them could lead to major errors if possible remedial measures are not implemented in time. A Patient Safety Committee composed of hospital staff reviews the reported errors in a timely manner and dispatches its recommendations. Johns Hopkins University School of Medicine (Baltimore, Maryland) has perhaps the most advanced system of reporting errors that incorporates all the characteristics enumerated above.
Johns Hopkins pioneered the Intensive Care Unit Safety Reporting System (ICUSRS), which is now implemented in scores of ICUs across the country. This system has a central database which collects data from all the hospitals hooked into the system. The ICURS is a part of the larger effort of improving patient safety by bringing down the rate of error, alongside JCAHO. Other procedures in place at Johns Hopkins have attempted to rationalize and streamline the process of delivering healthcare, so that the scope of errors in minimized.
For example, doses of medication go through multiple checks by physician, nurse and the pharmacist. Many hospitals participating in the program have, for example, reported near-disappearance of bloodstream infections in their ICUs (Journal of Oncology Practice). Another example of best practices is the system developed at Keystone Center for Patient Safety & Quality in Michigan, in operation since 2003. More than 125 ICUs in Michigan and other states have been participating in this system.
The Keystone Center has been instrumental in developing and implementing a series of interventions in the ICU setting which include a number of objectives, such as improving communications, reduce ICU mortality, improving the care of patients on ventilators, and reducing the incidence of bloodstream infections. A strong spirit of collaboration between the hospitals participating in this program has brought about a number of significant changes that promote patient safety.
Considering the enormous numbers of fatalities that occur as a result of medical errors, there is a need for massive initiative in the healthcare industry to bring these numbers down. Campaigns like Institute for Healthcare Improvement’s 100,000 Lives Campaign has enlisted a wide network of hospitals across the nation in the effort of bringing down the number of medical error associated fatalities. This campaign started with an objective of saving around 100,000 people from becoming victims of medical errors, over a span of 18 months.
The campaign has adopted a six-pronged strategy to attack the adversary, i. e. , adverse medical events caused by mistakes: • Prevent adverse drug reactions by using medication reconciliation. • Use rapid-response teams to respond to staff concerns about a patient’s condition, before the patient suffers a cardiorespiratory arrest or other emergency. • Improve care for acute myocardial infarctions, including using strict evidence-based protocols and automated systems to ensure patients who have suffered a myocardial infarction receive needed medications.
• Prevent surgical site infections by using protocols to ensure the correct perioperative antibiotics are given at the proper time. • Prevent central-line infections by accurately implementing a series of interdependent, scientifically based steps. • Prevent ventilator-associated pneumonia by accurately implementing a series of interdependent, scientifically based steps. By the end of its first 18-month campaign in June 2006, this campaign has succeeded in bringing down the number of hospital fatalities due to medical errors by an estimated 122,000 cases.
Central-line infections and ventilator-associated pneumonia have been eradicated in a number of ICUs among the hospitals that participated in the campaign. The general effort of patient safety advocates is to foster a culture of safety in American hospitals. The traditional work culture in the healthcare industry has to undergo substantial changes, this can happen only by active inculcation of new values. Lehigh Valley Hospital and Health Network in Allentown, Pennsylvania designed an interactive workshop to educate and train its staff members to report near misses and prevent errors from happening in other ways.
Continued training in combination with implementation of error-reducing strategies have significantly contributed to the reduction of morbidity and mortality in a number of hospitals all over the country. Every error has more than one or more root causes which can, in theory, be eliminated. What remains to be seen is how far practice can coincide with theory. Ultimately, the growing culture of safety should be a part of an ideal medical practice model based on the principles of patient-centered care of high-quality and extreme efficiency.
Works Cited AHRQ. “Glossary. ” Agency for Healthcare Research and Quality. http://www. psnet. ahrq. gov/glossary. aspx Childs, Dan. “Medical Errors, Past and Present. ” ABC News / Health. 27 Nov 2007. http://abcnews. go. com/Health/story? id=3789868;page=1 Croskerry, Pat, Karen S Cosby, Stephen M Schenkel, Robert L Wears. “Patient Safety in Emergency Medicine. ” Philadelphia, PA : Lippincot Williams ; Wilkins, 2009 Joint Commission. “Joint Commission Fact Sheets: Facts about the Sentinel Event Policy. ” 10 Sep. 2009. http://www.
jointcommission. org/AboutUs/Fact_Sheets/sep_facts. htm Joint Commission International. “Understanding and Preventing Sentinel and Adverse Events in Your Health Care Organization. ” Oakbrook Terrace, IL : Joint Commission Resources, 2008 Joint Commission Resources. “Root Cause Analysis in Health Care: Tools and Techniques. ” Oakbrook Terrace, IL : JCAHO, 2005 Journal of Oncology Practice. “Medical Errors: Focusing More on What and Why, Less on Who. ” J Oncol Pract 3: 2. Pp. 66-70. March 2007. http://jop. ascopubs. org/cgi/content/full/3/2/66