Advancing Patient Safety:A Snapshot History
Tort Reform Efforts (1975-96) Willie King/Rolando Sanchez case (1995) Betsy Lehman Case (1995-96) 104th Congress (“Contract with America”) (1995-96)
Anesthesia Patient Safety Foundation (1985) Leape’s Error in Medicine article (JAMA 1991) Ben Kolb case (1995)
First Annenberg conference (1996) VA implementation efforts & NPSF (1997) IOM1 Report (1999) -- a new plateau IOM2 Report (2001) -- milestone or miss (or both)?
What is a Safety Culture? How Do We Build it?
Problem - No Precedents in Health Care
Solution? Look at High Reliability Service Organizations in other fields
HRO’s are engineered to deliver consistently Good Outcomes in Complex & Dynamic Environments
How Did Other Fields Achieve High Reliability?
HRO Key Attributes…
Reporting Cultures Flexibility in Operation Perceived to be Just Engaged in and dedicated to
Learning
Advancing Patient Safety:Three Fronts of Engagement
The Challenges…
Transforming the External Environment Fostering a New Understanding of
Accountability
Transforming the Internal Environment Growing Internal Cultures that Honor Safety &
Deliver High Reliability Service
More Effectively Managing Knowledge Capturing Safety Information & Converting it
to Practical Tools
Growing a Safety Culture:Knowledge Sources
Health Care Research Systems Analysis, Engineering &
Design Cognitive Psychology Human Factors/Ergonomics Sociology & Organizational Behavior Lessons Learned from other Industries Quality Improvement Complexity Theory
Growing a Safety Culture: The Stakeholders
Consumers The Clinician/Patient/Family Team Health Care Administrators Makers & Purchasers of Medical Products Educators Employers, Payors & Managed Care Orgs Legislators/Regulators/Lawyers Media
The Patient Safety Paradox
We have…
New Technological “Miracles” Pushing Health Care Forward
Ability to Treat Ever Sicker Populations
The Patient Safety Paradox
But we also have…
Increased Process Complexity Escalating Change Information Overload Increased Expectations for
Perfect Outcomes New Patient Vulnerabilities
The Accountability Paradigm
The “Old Look”
Clinicians are Supposed to be Infallible
Bad Things Happen Only when People Make Mistakes
People/Organizations that Fail are Bad
Blame & Punishment Sufficiently Motivate Carefulness
The Accountability Paradigm
The “New Look”
Risk of Failure is Inherent in Complex Systems
Risk is always Emerging Latent Risk is not Foreseeable People are Fallible…No Matter How
Hard They Try Not to Be Systems are Fallible Alert, Well-trained Clinicians are
Crucial
To Err is Human (1999)The IOM Call to Action
Create a National Center for Patient Safety Establish Mandatory Reporting via State Agencies
to Ensure Accountability Encourage External Voluntary Reporting Pass Legislation for “Peer Review” Protection of
External Reporting Programs Raise Standards & Expectations for Safety Through
the Actions of Oversight Organizations, Purchasers, Professional Groups, etc.
Implement Proven Medication Practices by Creating Safety Systems Inside Health Care Organizations
Patient Safety Key Concepts
The Buzz Words...
Growing a Safety CultureThe Buzz Words
1. Patient Safety As a “Core Value”
2. “Human Factors” Engineering
3. “Errors” vs. “Recovery” vs. “Adverse Events”
4. “Near Misses” = “Near Hits” = “Close Calls”
Growing Safety CulturesThe Buzz Words
5. “Swiss Cheese” Model of Complex System Performance
6. “Latent Failure”
7. “Hindsight Bias”
8. “Blunt End vs. Sharp End”
Swiss Cheese Model
Modified from Reason, 1991 © 1991, James Reason
Triggers
DEFENSES
Accident
Regulatory Narrowness
Incomplete Procedures
Mixed Messages
Production Pressures
Responsibility Shifting
Inadequate Training
Attention Distractions
Deferred Maintenance
Clumsy Technology LATENT
FAILURES
Goal Conflictsand Double Binds
The World
Modified from Richard I. Cook, MD (1997)
Hindsight Bias
Before the Accident
After the Accident
Sharp and Blunt Ends
Errors and Expertise
Monitored Process
Organizations, Institutions,Policies, Procedures, Regulations
Resources andConstraints
Practitioner
Knowledge
Focus of Attention
Goals
Modified from Woods, et al., 1994
Sharp and Blunt Ends
The Sharp End
Consumers
Media, Legislators, Regulators, Lawyers, Accreditors, Educators
Resources andConstraints
Health Care Organizations
Administrators
Clinicians, Families, Patients
Pr. Buyers
Modified from Woods, et al., 1994
Employers/Payors & Product Makers
Advancing Patient Safety: Legislative Action in 2001?
Federal Health Legislation Priorities pre-IOM2
“Safe Harbor” Reporting Protection
Nursing Shortage Interventions Patient Bill of Rights Increased Funding for AHRQ Remedies for the Uninsured?
Advancing Patient Safety: What Have the States Done?
Post-IOM1 Legislation Introduced..
Fifteen states (eleven referencing IOM Report)
Forty-five bills Eight enacted -- FL, MA(2), MO, NY,
SD, WA(2) Ten pending Three tabled for later consideration
Advancing Patient Safety: What Have the States Done?
State Legislation Themes...
Whistle-blower protection Adequate nurse staffing Increasing info to consumers Establishing government
supported patient safety centers Expanded error reporting
Advancing Patient Safety: New Regulations and
Standards
Florida ruling on Medicare access to adverse event info
Expanded PRO activity New JCAHO standards Increased oversight/training in
ambulatory care Multifaceted AHRQ activities
Advancing Patient Safety: Employer/Purchaser
Initiatives
Leapfrog Group Initiatives Computerized medication/order
entry Intensivists in the ICU High volume centers
WBGH focus on medication management
VA initiatives on bar coding, etc.
IOM2: Crossing the Quality Chasm A New Health System for
the 21st Century
So, Does IOM2 mark a change in direction?
Reinforcement of the course set by IOM1?
A different call to action?
And, who’s listening?
Who’s opposing?
IOM2: Crossing the Quality Chasm A New Health System for
the 21st Century
Six Aims -- Health Care should be: Safe - No unintended injuries Effective - Based on evidence Patient-Centered Timely - No harmful delays Efficient - Waste avoided Equitable - No variance in quality
IOM2: Crossing the Quality Chasm A New Health System for
the 21st Century
13 Recommendations/4 Themes: Vision Redesign of the delivery
system Building organizational
supports for change Environmental changes
IOM2: Crossing the Quality Chasm A New Health System for
the 21st Century
Vision: Adopt Explicit Goal to
Improve Quality Every HCO Pursues the 6
Aims Congress to provide funds for
establishing and evaluating progress in achieving 6 Aims
IOM2: Crossing the Quality Chasm A New Health System for
the 21st Century
Delivery System Redesign: Every stakeholder follows same
basic rules & works together AHRQ identifies 15 conditions
and makes progress in 5 years Congress establishes $1 billion
HC Quality Innovation Fund
IOM2: Crossing the Quality Chasm A New Health System for
the 21st Century
Building Organizational Support for change: AHRQ convenes workshops to
promote state-of-art change DHHS supports effort to make
knowledge more accessible National commitment to
infrastructure improvement
IOM2: Crossing the Quality Chasm A New Health System for
the 21st Century
Environmental Changes: Purchasers remove barriers that
impede quality improvement AHRQ and HCFA explore options for
better alignment Clinician education re-examined Legal & regulatory reform studied
Advancing Patient Safety: Is the Media Helping or
Hurting?
Philadelphia Enquirer Series (Spring 2000) Chicago Tribune Series on Nurses (Summer
2000) Florida Ambulatory Care Stories (Summer/Fall
2000) Minneapolis Children’s Hospitals Challenges “Public Relations” Apologies
Growing a Safety Culture in Medicine -- The Road Map
Progress through alignment…
Based on Core Values (First Do No Harm) Focused on Delivery Process Redesign Supported by state-of-art knowledge management
infrastructure Encouraged by payment incentives Not discouraged by legal or regulatory threats Advanced by cooperation among all stakeholders
Advancing Patient Safety:A Lesson from Aviation
“One reason that an incident reporting system worked in aviation...was that the entire aviation community -- essentially all of the stakeholders, including air passengers -- were involved in the process from the beginning and became advocates for the reporting system (as well as severe, but constructive, critics).”
Charles E. Billings, MD, Editorial Arch Pathol Lab Med 1998,
121:214-215