News: Curing the medical mistakes epidemic

June 1, 2009

Patient safety was one of the most important topics at this year's Annual Clinical Meeting at ACOG.

Patient safety may not have been the most exciting topic featured at this year's Annual Clinical Meeting, but there's little doubt that it was one of the most important. Making patient care safer and preventing mistakes requires clinicians to "embrace a new way of thinking called systems thinking, as opposed to thinking about individual perfection," according to Robert M. Wachter, MD, who delivered one of the keynote addresses. Emphasizing the value of the "Swiss cheese model," the UCSF professor pointed out that the root cause of many accidents is not individual human error but built-in glitches or holes in the layers of an organization's protective measures. A major part of the root cause of many incidents, experts at the ACOG meeting said, is the current culture of medicine, including a rigid, hierarchical system in which nurses, residents, and technicians are too intimidated to question the authority of older, more senior physicians.

The need for cultural change was further driven home during a plenary session at which Paul A. O'Neill, former CEO of ALCOA, explained how his organization drastically reduced workplace errors-reducing the employee accident rate by more than half, making it the second safest industrial company in the US: Part of the solution involved creating an environment in which every single staffer was treated with dignity and respect, by everyone on the team, everyday, regardless of educational level, race, age, or job responsibilities.

Mr. O'Neill's session was part of a much larger discussion chaired by Paul Gluck, MD, of the National Patient Safety Foundation. Dr. Gluck's presentation focused on root causes of medical errors, not the least of which is poor patient-doctor communication. And one of the leading causes of this epidemic is low health literacy. He pointed out that much of what passes for written patient education materials is still written at a reading level beyond the average patient's comprehension. With that in mind, his organization helped develop the AskMe3 Program. It aims to provide clinicians with the tools to cure health illiteracy. One of the most useful tools they make available on their Web site (http://www.npsf.org/askme3/for_patients.php/) is the "Ask Me 3" patient brochure, which teaches patients not to walk away from a doctor's visit until they have the answers to 3 basic questions: What's my main problem? What do I need to do? Why is it important for me to do this?