The patient safety edition

If you read this blog on a somewhat regular basis, you’ve more than likely noticed I’m a bit obsessed about patient safety. I come by it honestly. Personal experiences such as a case of mistaken identity, which I blogged about in this post, and a close call with a wrong-site surgery, described here, tend to make you highly aware of the potential for things to go wrong.

So I couldn’t let national Patient Safety Awareness Week go by without posting at least a few links to some patient safety-related reading, starting with this excellent New York Times interview with Dr. Peter J. Pronovost, medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, Md. (If his name sounds familiar, it’s because he has done some ground-breaking research on the effectiveness of checklists to prevent errors.) In the interview, Dr. Pronovost delivers some frank talk about hospital safety, especially about preventing hospital-acquired infections.

One of the points Dr. Pronovost makes is that health care professionals are often their own worst enemies when it comes to providing safer care. Why is this? Most doctors are smart, perfectionistic and dedicated to high standards, but their training doesn’t seem to have prepared them well in the skills required to understand patient safety issues or to work collaboratively in analyzing errors and designing safer systems. This is the premise of a newly issued report, developed by the Lucian Leape Institute at the National Patient Safety Foundation and titled “Unmet Needs: Teaching Physicians to Provide Safe Patient Care.”

Here’s an excerpt that lays it on the line:

Medical schools today focus principally on providing students with the knowledge and skills they need for the technical practice of medicine, but often pay inadequate attention to the shaping of student skills, attitudes, and behaviors that will permit them to function safely and as architects of patient safety improvement in the future. Specifically, medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care, to wit: systems thinking, problem analysis, application of human factors science, communication skills, patient-centered care, teaming concepts and skills, and dealing with feelings of doubt, fear and uncertainty with respect to medical errors.

The full report can be downloaded here.

At the Agency for Healthcare Research and Quality, the Web-based morbidity and mortality rounds feature an ongoing series of “Perspectives on Safety.” In-depth articles and interviews with experts explore issues such as health literacy, disruptive physician behavior, surgical errors, medication bar coding and more. It quickly becomes clear that patient safety is complex, involving multiple factors that cannot be changed overnight.

Then there’s the human side of patient safety. Paul Levy, president and CEO of Beth Israel Deaconess Medical Center in Boston, is known as an advocate for patient safety and transparency. He also happens to be a prominent blogger at “Running a Hospital,” so when it was his turn a year ago to host the medblogosphere’s weekly grand rounds, he chose to collect personal stories about medical error. The result is “When things go awry.” Take some time to follow the links and read all the stories, which represent the experiences of health care professionals as well as patients.

It’s not hard to sympathize with patients and families when something goes wrong. But what about the doctors, nurses, pharmacists and other health care providers involved in an error, especially when it’s an error that harms or kills a patient? I think it’s safe to say clinicians invariably suffer as intensely as the patient and family – maybe even more so - yet often receive little support to help them heal. Caring for clinicians after an adverse event has long been a missing, but vital, piece in the response to medical error. A symposium last year, sponsored by a coalition that included Medically Induced Trauma Support Services of Massachusetts, explored this missing link and what can be done to support health care professionals more effectively. The full report is posted on the MITSS Web site and can be downloaded here.

I’d be remiss if I didn’t also post some basic information for patients and families about what they can do to reduce the likelihood they’ll be on the receiving end of a medical error. Here’s the National Patient Safety Foundation’s patient and family safety page, which contains several links and other resources. The Web site of the Minnesota Alliance for Patient Safety is here. And here’s the consumer medication safety page of the Institute for Safe Medication Practices; it contains a lot of valuable information about the safe use of prescription and over-the-counter medications.

I think we need to be careful about overplaying the ability of patients to influence the safety of their own care. Many things can go wrong over which patients have little, if any, control, and the guilt and self-blame they may feel after an adverse event should not be underestimated. But there are many things patients can do that help make a difference. A little knowledge and empowerment often go a long way.

Update, March 15: Here’s an insider’s perspective from Dr. Pauline Chen, who writes for the New York Times about the doctor-patient relationship. The online discussion can be found here. A couple of thoughts come to mind. First, what Dr. Chen describes seems to be more than a culture of fear; it’s also a culture of hierarchy and dysfunction, in which incident reports about patient harm are used as a weapon instead of a tool for learning. Second, judging from the readers’ comments, it’s incredibly difficult to have a constructive conversation about how to improve patient safety. Doctors get defensive; the public resorts to doctor-bashing. How are we supposed to make any progress in the face of this siege mentality?

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