- Email: [email protected]
Two Sides to the Bed: Physician-Patient and Physician-Friend
Two Sides to the Bed: Physician-Patient and Physician-Friend Alison S. Clay, MD,* Nancy Knudsen, MDy Errors can happen in the most accomplished of systems, and healthcare providers need a better understanding of what effect these errors have on patients, what we must do to respond to errors, and what we can do to prevent them. The authors describe a medical error from the perspectives of both physician-patient and physician-friend, identifying key blessons learnedQ and strategies for preventing similar errors from occurring in other healthcare settings. Clin Ped Emerg Med 7:261-264 ª 2006 Elsevier Inc. All rights reserved. KEYWORDS patient vulnerability, medical error
Alison’s Side of the Bed The day could not have been more perfect: a new bike, radiant sun beams, majestic silent timbers, and the music of flirtatious song birds. Joyously anticipating my first 3 hours on my new bike, I did not notice the honeybee on my foot until it stung me on my little toe. With no shortness of breath, I was oblivious to the storm clouds that had just rolled into my life. Fifteen minutes later, with erythema to my thigh, I drove myself to the emergency department, more concerned about my bike ride than about my health. On arrival, my temperature was 103, my pulse was in the 140s, and I was diaphoretic and vomiting. Fortunately, the emergency department more accurately assessed my condition than I had. I received intravenous steroids and antihistamines less than 15 minutes after my arrival. But I deteriorated, coughing and choking. Epinephrine was ordered, I was moved to a shock room. My saturations started to drop. I tried to calm myself as the nurse approached with a dose of epinephrine. This was reversible. Things would be *Departments of Surgery and Medicine, Duke University Medical Center, Durham, NC. yDepartment of Anesthesiology, Duke University Medical Center, Durham, NC. Reprint requests and correspondence: Alison S. Clay, MD, Box 2945 Med Ctr, Durham, NC 27710. (E-mail: [email protected]) 1522-8401/$ - see front matter ª 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.cpem.2006.08.004
fine. As the nurse pushed the epinephrine intravenously, I remember anticipating tachycardia. When I felt a sense of impending doom, I tried to breathe deeply and reassure myself by reviewing the pharmacologic effects of epinephrine. This was normal. I looked up to the telemetry box expecting narrow, rapid, QRS complexes only to see ventricular tachycardia. I screamed for help. The attending appeared, asking if intramuscular epinephrine had been given yet. bIM?Q I ask, bIt was given IV.Q The nurse denied this. A parade of sequential observers (all with increasing rank) inspected my right deltoid for evidence of a recent intramuscular injection. My saturations drop. Respiratory is called. I am being intubated. In the next 3 days, my nightmare will continue. I developed hyperkalemia with heart block when my potassium is oversupplemented in the setting of oligura and b-agonists. Having been intubated previously for a preexisting metabolic myopathy, I will be extubated after warning the team that it was too early, only to be reintubated 4 hours later. When I finally started to improve, I will remember the irony of being told that the team needed to watch me one more day bjust to make sure I was safe.Q Although dramatic, mine is not a unique story. Hundreds of thousands of patients each year experience medical errors while they are being cared for in the hospital. Almost 100,000 people will die—I am one of the lucky ones. I also may have insight that others do not—as a physician, I have intimate knowledge of life on both 261
262 sides of the bed. Although others may wonder about the competence of their physicians, I know, beyond doubt, that the people caring for me are extremely competent, compassionate, and experienced. I know they had my best interests in mind; and I have learned how easy it is to violate a patient’s trust even when you do not intend to, even when you are trying your best; and I know we must do something about it. Errors can happen in the most accomplished of systems, and we need better understanding of what effect these errors have on patients, what we must do to respond to errors and what we can do to prevent them. We do this from the perspectives of both physicianpatient and physician-friend.
Nancy’s Side of the Bed One night on call, I was asked to take a MICU patient in transfer so the unit staff could bring in someone who needed to be intubated, but who could not be admitted to our unit because he/she knew the people there. I offered my services as an anesthesiologist if needed. Thirty minutes later, I was called to the Medical Intensive Care Unit and went up to find Alison with classic signs of impending respiratory failure: hypoxia, tripoding, tachypnea, accessory muscle use, and inability to speak. Everyone stood outside the room discussing the case, but no one was with Alison making her more comfortable. She had been reduced to a medical decision; defense mechanisms had kicked in for the staff who knew her. The emergency airway team was called to intubate Alison. Knowing she would be taken care of, I stood by Alison as her friend, holding her hand and talking with her throughout the intubation.
Lessons Learned from Both Sides of the Bed
A.S. Clay, N. Knudsen often hard to believe that a mistake was made. The natural reaction is to prove that the error did not happen, or if it did, that it did not cause harm. However, this defensive posture only results in patients feeling more disenfranchised, more vulnerable, and more skeptical of the system.
Lesson 3: Apologies are Very Important One way to acknowledge patient vulnerability and diffusion of trust is to acknowledge and apologize for errors. Silence only solidifies a patient’s feelings.
Lesson 4: Teams May Not Listen to Patients and Their Families As physicians we think we know best. We possess a lot of general medical knowledge, but patients and families possess individual knowledge that can improve patient care if we will listen.
Lesson 5: Errors Happen Frequently It is amazing how easy it is for a confluence of little errors to result in a big error, often in a way that has never happened before.
Lesson 6: Many Errors are Never Reported and Therefore Cannot be Prevented in the Future In this era of increased concern for patient safety, not only do we need to do a better job reporting adverse events, we also need to do a better job disseminating information learned in one area throughout the institution and potentially to other centers. These lessons have changed how we personally practice medicine. Unfortunately, it has been difficult to try to change the system, in part because of our lack of objectivity. Our colleagues have been tremendous catalysts for impacting future care and for thinking about how to address problems within the system.
Following these experiences, we have identified 6 specific lessons learned.
Lesson 1: Patients are Vulnerable
Solutions for Practice Change
As a patient, you place tremendous trust in the system and your caregivers. When you perceive that an error happened, you question your trust. Any subsequent action is viewed in the context of the previous one. If your trust has been violated, you view subsequent actions suspiciously, even if the caregiver is different.
Reflecting on these lessons learned, we have developed possible solutions that may help to change practice and to prevent other patients from having similar experiences.
Lesson 2: Patients May Feel Blamed for Errors Not only does an error make a patient feel more vulnerable and cause the patient to question his/her care, it also increases vulnerability if the patient reports an error. Caregivers invest so much energy into care that it is
Solution 1: Empower Patients, Families, and All Members of the Healthcare Team Many organizations, including The Institute for Healthcare Improvement, the Institute of Medicine, and the Robert Wood Johnson Foundation, have stated that patient-centered care is the key to quality improvement and patient safety in healthcare [1,2]. The Institute for Healthcare Improvement defines patient-centered care as care that involves patients and their families in the design
Two sides to the bed of care, reliably meets patient needs and preferences, and has informed, shared decision making [1]. One way to help change our attitude toward patient care is to advocate and pursue team training and crew/ crisis resource management. Just as pilots needed to learn to accept advice from their copilots, flight crew, and mechanics [3,4], physicians need to learn to respect the advice of others, not only patients and their families but also medical students, unit secretaries, environmental services—anyone who has the opportunity to witness problems with patient care. Often, those who know less about bwhat to expectQ or who are less involved in a specific task have a clearer vision about what is going on around them [5]. This is tremendously powerful information to a team, but the team must be willing to listen and act, to believe that everyone has something to contribute.
Solution 2: Acknowledging and Apologizing for Errors In the past, hospital risk management has not been a strong advocate for error disclosure, and both managers and physicians fear litigation as a result of disclosure [6,7]. As a result, many physicians and residents do not disclose errors to patients or their families [8-11], although patients expect physicians to do so [9,12,13]. Acknowledging error properly may increase patient satisfaction and may reduce the risk of litigation [9,12-14]. The first step toward error disclosure is a change in the culture of our healthcare systems— reporting must be expected instead of discouraged and must be linked more toward preventing future harm than in punishment for past harm [15-17]. Not only must medical systems change their policies toward disclosure of errors, but they also must invest in training for physicians on how to disclose errors. Properly executing apologies requires understanding the patient situation, empathically admitting the error (confession), recognizing the impact (harm) from the error, apologizing genuinely for the error (repentance), and making every effort to avoid those situations for the patient and other patients [18-20]. Failure to properly disclose or explain an error or being unsympathetic may actually be what prompts some families to pursue litigation [21,22]. When talking with families, physicians must learn the critical pieces of disclosing error, something many physicians do not know how to do [23]. In addition, hospitals must invest resources to support error disclosure. Often, physicians themselves feel guilt for an error. Before talking to families, physicians must have the opportunity to discuss the errors and their feelings with other colleagues or support staff [18-20]. In addition, healthcare systems must be willing to compensate patients and their families for errors. Data show that when errors are disclosed and immediate compensation is
263 offered, patients often settle with the hospital instead of pursuing litigation or have lower pay-outs than when apologies are not offered [24,25].
Solution 3: Proactive Collection of Data About Harm and Prevention of Error Hospitals must be willing to collect data on harm in the hospital. Although many healthcare systems have adopted voluntary reporting systems to document errors that are witnessed by healthcare providers, these systems may miss many errors. Healthcare workers may fear punishment for entering errors, may not know how to use the system, or may have no incentive to do so [7]. Patients and their families often witness error and have motivation to report the error but have no mechanism for doing so. Recent studies have shown that patients accurately report error, both when offered the opportunity to report error using a checklist or when offered open-ended questions [26,27]. Patients report events that have not been captured by other reporting systems [26,27]. Asking for patient opinions can be a powerful component of empowering patients and their families. Hospitals would also benefit from offering continuous improvement programs that allow experienced workers to offer suggestions for change before an error happens. Business has successfully used continuous improvement programs to improve productivity and to improve safety [28]. Success with patient reporting and continuous improvement programs is dependent on timely response to suggestions. Although monetary incentives increase submissions, success is not dependent on these incentives. People want to know that they have been heard. Simply acknowledging reports to the individuals who submitted them increases reporting and makes a powerful impression about the environment of the healthcare system and the personal responsibility that each person bears for patient safety.
Solution 4: Preventing Repeat Errors—for Both the Patient and the System When an error does happen, it is critically important that the error not be repeated, both for that particular patient and for other patients. Hospital systems must invest in mechanisms to disseminate information about error. For an individual patient, errors made in one part of the hospital must be communicated to other teams participating in the care of the patient so that teams can be sensitive to changes in a patient’s trust. Very often, medical errors that do occur are not documented in the medical record [26,27]. For example, a brightly colored berror reportQ could be placed on the front page of the patient’s chart and/or the electronic medical record could have an area next
264 to ballergies and intolerancesQ where patient concerns/ errors could be briefly entered. The hospital system must also find a way to disseminate information about errors made within the healthcare system. Many voluntary reporting systems provide information to those that entered the report and to the medical directors of the areas where those errors occurred. However, physicians and nurses within that care area or even other areas of the same hospital often have no idea about the errors that are made. This information could be disseminated using daily bremindersQ on hospital computers screens (ie, bLast month, there were four falls from beds in this hospital. Are you making sure all bed rails are up?Q) or by providing information on the number and types of reports publicly at, for example, departmental grand rounds.
Summary As physician-patient and physician-friend, we tell you about this particular case not to frighten or anger but to prompt discussion about how we might all change our practice and the practices within our institutions to prevent other patients from having similar experiences.
References 1. Institute for Healthcare Improvement. Patient centered care. Available at: http://www.ihi.org/IHI/Topics/PatientCenteredCare/; 2006 [Accessed 8/4/06]. 2. Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, (DC): National Academy Press; 2001. 3. Fisher J, Phillips E, Mather J. Does crew resource management training work? Air Med J 2000;19:13729. 4. Hedge JW, Bruskiewicz KT, Borman WC, et al. Selecting pilots with crew resource management skills. Int J Aviat Psychol 2000; 10:377292. 5. Simons RJ, Chabris CF. Gorillas in our midst: sustained inattentional blindness for dynamic events. Perception 1999;28:1059274. 6. Weissman JS, Annas CL, Epstein AM, et al. Error reporting and disclosure systems: views from hospital leaders. JAMA 2005; 293:1359266. 7. Waring JJ. Beyond blame: cultural barriers to medical incident reporting. Soc Sci Med 2005;60:1927235. 8. Allman J. Bearing the burden or baring the soul: physicians’ selfdisclosure and boundary management regarding medical mistakes. Health Commun 1998;10:175297. 9. Mizrahi T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Soc Sci Med 1984;19: 135246.
A.S. Clay, N. Knudsen 10. Wu AW, Folkman S, McPhee SJ, et al. Do house officers learn from their mistakes? JAMA 1991;265:2089294. 11. Lehmann LS, Puopolo AL, Shaykevich S, et al. Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions. Am J Med 2005;118:409213. 12. Mazor KM, Simon SR, Yood RA, et al. Health plan members’ views about disclosure of medical errors. Ann Intern Med 2004; 140:409218. 13. Hobgood C, Tamayo-Sarver JH, Elms A, et al. Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children. Pediatrics 2005;116:1276286. 14. Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med 1996;156:256529. 15. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive accreditation manual for hospitals: the official handbook. Oakbrook Terrace (Il): Joint Commission on Accreditation of Healthcare Organizations; 2004. 16. Massachusetts Coalition for the Prevention of Medical Errors. When things go wrong: responding to adverse events. A consensus statement of the Harvard hospitals. Available at: http://www.ihi.org/ IHI/Topics/PatientSafety/SafetyGeneral/Literature/WhenThingsGoWrongRespondingtoAdverseEvents.htm [Accessed 8/4/06]. 17. Connor M, Ponte PR, Conway J. Multidisciplinary approaches to reducing error and risk in a patient care setting. Crit Care Nurs Clin North Am 2002;14:359267. 18. Gallagher TH, Waterman AD, Ebers AG, et al. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003;289:100127. 19. Pollack C, Bayley C, Mendiola M, et al. Helping clinicians find resolution after a medical error. Camb Q Healthc Ethics 2003; 12:20327. 20. Berlinger N, Wu AW. Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error. J Med Ethics 2005;31:10628. 21. Hickson GB, Clayton EW, Githens PB, et al. Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA 1992;267:1359263. 22. Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994; 343:1609213. 23. Chan DK, Gallagher TH, Reznick R, et al. How surgeons disclose medical errors to patients: a study using standardized patients. Surgery 2005;138:85128. 24. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med 1999;131:96327. 25. Robbennolt JK. Apologies and legal settlement: an empirical examination. Mich Law Rev 2003;102:4602516. 26. Agoritsas T, Bovier PA, Perneger TV. Patient reports of undesirable events during hospitalization. J Gen Intern Med 2005; 20:92228. 27. Weingart SN, Pagovich O, Sands DZ, et al. What can hospitalized patients tell us about adverse events? Learning from patientreported incidents. J Gen Intern Med 2005;20:83026. 28. Liker JK, Gardner G. The Toyota way. Burlington (NC): McGrawHill Audio; 2004.
Alison’s Side of the Bed The day could not have been more perfect: a new bike, radiant sun beams, majestic silent timbers, and the music of flirtatious song birds. Joyously anticipating my first 3 hours on my new bike, I did not notice the honeybee on my foot until it stung me on my little toe. With no shortness of breath, I was oblivious to the storm clouds that had just rolled into my life. Fifteen minutes later, with erythema to my thigh, I drove myself to the emergency department, more concerned about my bike ride than about my health. On arrival, my temperature was 103, my pulse was in the 140s, and I was diaphoretic and vomiting. Fortunately, the emergency department more accurately assessed my condition than I had. I received intravenous steroids and antihistamines less than 15 minutes after my arrival. But I deteriorated, coughing and choking. Epinephrine was ordered, I was moved to a shock room. My saturations started to drop. I tried to calm myself as the nurse approached with a dose of epinephrine. This was reversible. Things would be *Departments of Surgery and Medicine, Duke University Medical Center, Durham, NC. yDepartment of Anesthesiology, Duke University Medical Center, Durham, NC. Reprint requests and correspondence: Alison S. Clay, MD, Box 2945 Med Ctr, Durham, NC 27710. (E-mail: [email protected]) 1522-8401/$ - see front matter ª 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.cpem.2006.08.004
fine. As the nurse pushed the epinephrine intravenously, I remember anticipating tachycardia. When I felt a sense of impending doom, I tried to breathe deeply and reassure myself by reviewing the pharmacologic effects of epinephrine. This was normal. I looked up to the telemetry box expecting narrow, rapid, QRS complexes only to see ventricular tachycardia. I screamed for help. The attending appeared, asking if intramuscular epinephrine had been given yet. bIM?Q I ask, bIt was given IV.Q The nurse denied this. A parade of sequential observers (all with increasing rank) inspected my right deltoid for evidence of a recent intramuscular injection. My saturations drop. Respiratory is called. I am being intubated. In the next 3 days, my nightmare will continue. I developed hyperkalemia with heart block when my potassium is oversupplemented in the setting of oligura and b-agonists. Having been intubated previously for a preexisting metabolic myopathy, I will be extubated after warning the team that it was too early, only to be reintubated 4 hours later. When I finally started to improve, I will remember the irony of being told that the team needed to watch me one more day bjust to make sure I was safe.Q Although dramatic, mine is not a unique story. Hundreds of thousands of patients each year experience medical errors while they are being cared for in the hospital. Almost 100,000 people will die—I am one of the lucky ones. I also may have insight that others do not—as a physician, I have intimate knowledge of life on both 261
262 sides of the bed. Although others may wonder about the competence of their physicians, I know, beyond doubt, that the people caring for me are extremely competent, compassionate, and experienced. I know they had my best interests in mind; and I have learned how easy it is to violate a patient’s trust even when you do not intend to, even when you are trying your best; and I know we must do something about it. Errors can happen in the most accomplished of systems, and we need better understanding of what effect these errors have on patients, what we must do to respond to errors and what we can do to prevent them. We do this from the perspectives of both physicianpatient and physician-friend.
Nancy’s Side of the Bed One night on call, I was asked to take a MICU patient in transfer so the unit staff could bring in someone who needed to be intubated, but who could not be admitted to our unit because he/she knew the people there. I offered my services as an anesthesiologist if needed. Thirty minutes later, I was called to the Medical Intensive Care Unit and went up to find Alison with classic signs of impending respiratory failure: hypoxia, tripoding, tachypnea, accessory muscle use, and inability to speak. Everyone stood outside the room discussing the case, but no one was with Alison making her more comfortable. She had been reduced to a medical decision; defense mechanisms had kicked in for the staff who knew her. The emergency airway team was called to intubate Alison. Knowing she would be taken care of, I stood by Alison as her friend, holding her hand and talking with her throughout the intubation.
Lessons Learned from Both Sides of the Bed
A.S. Clay, N. Knudsen often hard to believe that a mistake was made. The natural reaction is to prove that the error did not happen, or if it did, that it did not cause harm. However, this defensive posture only results in patients feeling more disenfranchised, more vulnerable, and more skeptical of the system.
Lesson 3: Apologies are Very Important One way to acknowledge patient vulnerability and diffusion of trust is to acknowledge and apologize for errors. Silence only solidifies a patient’s feelings.
Lesson 4: Teams May Not Listen to Patients and Their Families As physicians we think we know best. We possess a lot of general medical knowledge, but patients and families possess individual knowledge that can improve patient care if we will listen.
Lesson 5: Errors Happen Frequently It is amazing how easy it is for a confluence of little errors to result in a big error, often in a way that has never happened before.
Lesson 6: Many Errors are Never Reported and Therefore Cannot be Prevented in the Future In this era of increased concern for patient safety, not only do we need to do a better job reporting adverse events, we also need to do a better job disseminating information learned in one area throughout the institution and potentially to other centers. These lessons have changed how we personally practice medicine. Unfortunately, it has been difficult to try to change the system, in part because of our lack of objectivity. Our colleagues have been tremendous catalysts for impacting future care and for thinking about how to address problems within the system.
Following these experiences, we have identified 6 specific lessons learned.
Lesson 1: Patients are Vulnerable
Solutions for Practice Change
As a patient, you place tremendous trust in the system and your caregivers. When you perceive that an error happened, you question your trust. Any subsequent action is viewed in the context of the previous one. If your trust has been violated, you view subsequent actions suspiciously, even if the caregiver is different.
Reflecting on these lessons learned, we have developed possible solutions that may help to change practice and to prevent other patients from having similar experiences.
Lesson 2: Patients May Feel Blamed for Errors Not only does an error make a patient feel more vulnerable and cause the patient to question his/her care, it also increases vulnerability if the patient reports an error. Caregivers invest so much energy into care that it is
Solution 1: Empower Patients, Families, and All Members of the Healthcare Team Many organizations, including The Institute for Healthcare Improvement, the Institute of Medicine, and the Robert Wood Johnson Foundation, have stated that patient-centered care is the key to quality improvement and patient safety in healthcare [1,2]. The Institute for Healthcare Improvement defines patient-centered care as care that involves patients and their families in the design
Two sides to the bed of care, reliably meets patient needs and preferences, and has informed, shared decision making [1]. One way to help change our attitude toward patient care is to advocate and pursue team training and crew/ crisis resource management. Just as pilots needed to learn to accept advice from their copilots, flight crew, and mechanics [3,4], physicians need to learn to respect the advice of others, not only patients and their families but also medical students, unit secretaries, environmental services—anyone who has the opportunity to witness problems with patient care. Often, those who know less about bwhat to expectQ or who are less involved in a specific task have a clearer vision about what is going on around them [5]. This is tremendously powerful information to a team, but the team must be willing to listen and act, to believe that everyone has something to contribute.
Solution 2: Acknowledging and Apologizing for Errors In the past, hospital risk management has not been a strong advocate for error disclosure, and both managers and physicians fear litigation as a result of disclosure [6,7]. As a result, many physicians and residents do not disclose errors to patients or their families [8-11], although patients expect physicians to do so [9,12,13]. Acknowledging error properly may increase patient satisfaction and may reduce the risk of litigation [9,12-14]. The first step toward error disclosure is a change in the culture of our healthcare systems— reporting must be expected instead of discouraged and must be linked more toward preventing future harm than in punishment for past harm [15-17]. Not only must medical systems change their policies toward disclosure of errors, but they also must invest in training for physicians on how to disclose errors. Properly executing apologies requires understanding the patient situation, empathically admitting the error (confession), recognizing the impact (harm) from the error, apologizing genuinely for the error (repentance), and making every effort to avoid those situations for the patient and other patients [18-20]. Failure to properly disclose or explain an error or being unsympathetic may actually be what prompts some families to pursue litigation [21,22]. When talking with families, physicians must learn the critical pieces of disclosing error, something many physicians do not know how to do [23]. In addition, hospitals must invest resources to support error disclosure. Often, physicians themselves feel guilt for an error. Before talking to families, physicians must have the opportunity to discuss the errors and their feelings with other colleagues or support staff [18-20]. In addition, healthcare systems must be willing to compensate patients and their families for errors. Data show that when errors are disclosed and immediate compensation is
263 offered, patients often settle with the hospital instead of pursuing litigation or have lower pay-outs than when apologies are not offered [24,25].
Solution 3: Proactive Collection of Data About Harm and Prevention of Error Hospitals must be willing to collect data on harm in the hospital. Although many healthcare systems have adopted voluntary reporting systems to document errors that are witnessed by healthcare providers, these systems may miss many errors. Healthcare workers may fear punishment for entering errors, may not know how to use the system, or may have no incentive to do so [7]. Patients and their families often witness error and have motivation to report the error but have no mechanism for doing so. Recent studies have shown that patients accurately report error, both when offered the opportunity to report error using a checklist or when offered open-ended questions [26,27]. Patients report events that have not been captured by other reporting systems [26,27]. Asking for patient opinions can be a powerful component of empowering patients and their families. Hospitals would also benefit from offering continuous improvement programs that allow experienced workers to offer suggestions for change before an error happens. Business has successfully used continuous improvement programs to improve productivity and to improve safety [28]. Success with patient reporting and continuous improvement programs is dependent on timely response to suggestions. Although monetary incentives increase submissions, success is not dependent on these incentives. People want to know that they have been heard. Simply acknowledging reports to the individuals who submitted them increases reporting and makes a powerful impression about the environment of the healthcare system and the personal responsibility that each person bears for patient safety.
Solution 4: Preventing Repeat Errors—for Both the Patient and the System When an error does happen, it is critically important that the error not be repeated, both for that particular patient and for other patients. Hospital systems must invest in mechanisms to disseminate information about error. For an individual patient, errors made in one part of the hospital must be communicated to other teams participating in the care of the patient so that teams can be sensitive to changes in a patient’s trust. Very often, medical errors that do occur are not documented in the medical record [26,27]. For example, a brightly colored berror reportQ could be placed on the front page of the patient’s chart and/or the electronic medical record could have an area next
264 to ballergies and intolerancesQ where patient concerns/ errors could be briefly entered. The hospital system must also find a way to disseminate information about errors made within the healthcare system. Many voluntary reporting systems provide information to those that entered the report and to the medical directors of the areas where those errors occurred. However, physicians and nurses within that care area or even other areas of the same hospital often have no idea about the errors that are made. This information could be disseminated using daily bremindersQ on hospital computers screens (ie, bLast month, there were four falls from beds in this hospital. Are you making sure all bed rails are up?Q) or by providing information on the number and types of reports publicly at, for example, departmental grand rounds.
Summary As physician-patient and physician-friend, we tell you about this particular case not to frighten or anger but to prompt discussion about how we might all change our practice and the practices within our institutions to prevent other patients from having similar experiences.
References 1. Institute for Healthcare Improvement. Patient centered care. Available at: http://www.ihi.org/IHI/Topics/PatientCenteredCare/; 2006 [Accessed 8/4/06]. 2. Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, (DC): National Academy Press; 2001. 3. Fisher J, Phillips E, Mather J. Does crew resource management training work? Air Med J 2000;19:13729. 4. Hedge JW, Bruskiewicz KT, Borman WC, et al. Selecting pilots with crew resource management skills. Int J Aviat Psychol 2000; 10:377292. 5. Simons RJ, Chabris CF. Gorillas in our midst: sustained inattentional blindness for dynamic events. Perception 1999;28:1059274. 6. Weissman JS, Annas CL, Epstein AM, et al. Error reporting and disclosure systems: views from hospital leaders. JAMA 2005; 293:1359266. 7. Waring JJ. Beyond blame: cultural barriers to medical incident reporting. Soc Sci Med 2005;60:1927235. 8. Allman J. Bearing the burden or baring the soul: physicians’ selfdisclosure and boundary management regarding medical mistakes. Health Commun 1998;10:175297. 9. Mizrahi T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Soc Sci Med 1984;19: 135246.
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