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Systems Analysis Vs. Risk Management From: art fougner, md (evsono@pipeline.com) Thu May 27 12:24:04 2004 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Joanne Bulley, MD: "Re: cost of 'no shows'" Previous message: art fougner, md: "Re: cost of 'no shows'" Ob-gyns investigating model reforms to avoid medical error Patient Safety May 27, 2004 2004 MAY 27 - (NewsRx.com & NewsRx.net) -- A distinguished panel of patient safety experts said that obstetrician-gynecologists could take the lead in promoting model patient-safety reforms across the U.S. by learning from experts in another high-risk profession: aviation. Discussing the subject of a national, randomized controlled trial funded by the U.S. Department of Defense, Benjamin P. Sachs, MB, BS, DPD, of Beth Israel Deaconess Medical Center in Boston, Massachusetts, said that investigators are now reviewing whether 15 hospital obstetrics departments may benefit from safety techniques now used by all U.S. airlines and branches of the military. Speaking at a press briefing at the Annual Clinical Meeting of The American College of Obstetricians and Gynecologists (ACOG), Sachs noted that Crew Resource Management (CRM) techniques, which stress teamwork as a way to reduce potential for human error in complex enterprises, are widely used in the aviation industry. The Federal Aviation Authority has mandated CRM for all commercial airlines since 1997. "We are still awaiting the outcome of this team training study, which includes both civilian and military hospitals," said Sachs. "I do know that in my own hospital, where we adapted these techniques for obstetrics, the rate of adverse outcomes has declined 53% in the last 4 years. This suggests that better communication and teamwork can make childbirth safer." Sachs and other patient-safety experts were featured speakers during ACOG's opening President's Program. "Patient safety is a critical issue for American medicine," said ACOG President John M. Gibbons, Jr., MD. "The need for patient-safety reform and medical liability system reform are top issues on ACOG's agenda, and the two are deeply entwined." The effort to improve patient safety - by reducing the rate of avoidable medical errors in the healthcare system - has received national attention since the release of a 1999 Institute of Medicine (IOM) report. The IOM estimated that 1 million people are injured annually by errors in treatment at U.S. hospitals each year, with as many as 98,000 deaths arising from those errors. That's a death rate 1,000 times greater than that from commercial aircraft accidents. "As the American healthcare system grows more complex, the potential for human error only compounds," said Stanley Zinberg, MD, ACOG vice president for practice activities. "We in medicine can learn from those in aviation how to restructure our system to reduce the chances for human error." Zinberg noted that contrary to popular belief, most of the errors cited in the IOM report did not concern the issue of individual physician competency - the focus of the current medical tort system - as much as the system-wide problems that can sabotage patient care in hospitals or medical offices. These can include poor communication among departments or personnel; errors in identifying or tracking patients in busy hospitals or across specialties; or mistakes in dispensing medication, due to similar product names, poor handwriting, or confusing use of symbols in charts. CRM techniques were developed for use in aviation after the National Aeronautics and Safety Administration found in 1979 that human error and failures of communication were involved in a majority of aviation accidents. Rather than blaming individuals when something goes wrong, CRM encourages the open reporting, analysis, and improvement of events taking place within an organization. The IOM has speculated that such teamwork adapted for use by doctors, nurses, and hospital administrators could reduce medical errors in high-performance, high-stress environments such as emergency departments or labor and delivery rooms. Gibbons feels the current tort system is hurting, rather than helping, patient-safety reforms. "Our current liability system is a closed, punitive one, going after individuals and driving openness underground," he said. "We believe that patients who have been harmed deserve compensation and relief, but the tort system is not the arena to correct system-wide errors or enhance patient safety. If it were, our litigious culture would have corrected the problems noted in the IOM report." Lucian L. Leape, MD, MPH, a well-known patient-safety advocate from the Harvard School of Public Health, said that an effective patient-safety system gets away from a focus on blaming or punishing people for making mistakes, and rewards openness about the tracking and correction of errors. He noted both the progress and the setbacks in the growing national effort for improved patient safety. "The good news is that a number of forces in society are accelerating the patient-safety movement, and hospitals all around the country are implementing new safe practices, such as use of computer tracking systems or avoidance of certain terminology or abbreviations in charts," Leape said. Unfortunately, he added, barriers to improvement remain, including the fact that many physicians are still not actively involved in the development of new safety systems. "The CRM project may help us understand what can happen if doctors take the lead," he said. Leape, who served on the IOM panel on patient safety and has developed highly regarded error-prevention principles, calls the need to reduce medical errors a "moral imperative." In a speech at ACOG's opening session, he emphasized the need for hospitals and healthcare organizations to develop a "culture of safety" in which patient safety is "Job 1." He noted the devastating emotional effects that error-caused injuries can have on patients and the need for full and open disclosure with an apology when injuries occur. This article was prepared by Women's Health Weekly editors from staff and other reports. Copyright 2004, Women's Health Weekly via NewsRx.com & NewsRx.net. ©Copyright 2004, Cardiovascular Week via NewsRx.com & NewsRx.net http://www.obgyn.net/newsheadlines/womens_health-Patient_Safety-20040527-136.asp art -- art fougner, md ich bin ein New Yorker Next message: Joanne Bulley, MD: "Re: cost of 'no shows'" Previous message: art fougner, md: "Re: cost of 'no shows'"

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