Patient Safety: What's wrong with this picture?

June 1, 2004



It's a given: There would be fewer liability suits if there were fewer medical errors. But too few hospitals and clinicians seem to be addressing one fundamental issue: patient safety. According to one top expert in this undervalued specialty, the systems we have in place to protect patients and administer care have serious flaws, which require major changes in design and in the work flow process.

Speaking at the 2004 annual clinical meeting (ACM), Lucian Leape, MD, of Harvard School of Public Health, pointed out that "medical errors are not caused by bad people but by bad systems," and by a culture that has yet to put patient safety ahead of the medical pecking order. He used a simple example to drive home the point. In a culture that truly valued patients' well-being, if a physician were to forget to wash his or her hands before examining a patient, an attending RN would not hesitate for a moment to remind him to wash. And if he refused, this subordinate would not hesitate to report him to management. And management would welcome the report. In essence, Dr. Leape insisted that we need to create a culture in which patient safety is an organizational priority, and one that's supported by expertise, training, and information technology.

To address the practical implications of that philosophy, Benjamin Sachs, MD, from Beth Israel Deaconess Medical Center in Boston presented the results of a multicenter study that included seven labor and delivery units and over 47,000 deliveries. To see if a team approach and a systems redesign could reduce the number of clinical errors, his group used the Crew Resource Management (CRM) program that has reduced fatal errors on commercial airlines and in the military over the last two decades. Before the system was put in place in the hospitals, there were 26 "indemnity experiences"—malpractice claims and related incidents—among 13,000 deliveries at Beth Israel Deaconess Medical Center. That number dropped to 13 after the training. CRM also led to a 53% drop in the adverse outcome index in Dr. Sachs' hospital (results for all the L&D units involved in the study are not yet available). Equally encouraging, the company providing liability insurance for the Harvard-affiliated L&Ds actually lowered its premiums by 10%.

Although Dr. Sach's team has yet to release the details on the training program, he did outline some basics: 4 hours of classroom instruction that emphasized teamwork, problem solving, and better communication skills; and lots of hands-on training to re-educate L&D staffers to buy into the new culture.