Patient Safety Congress

Tuesday, January 01, 2013 12:26 PM

Invest in collaboration and communication to move patient safety forward

Kate Alfano, CMS contributing writer

When he was a second-year resident training at Boston Children’s Hospital, Don Berwick, MD, almost killed a baby. This was 1974, decades before his service as administrator of the Centers for Medicare and Medicaid Services, and he was on overnight duty at a neighboring hospital for his second-ever neonatal intensive care unit rotation.

At 3 a.m., a nurse called Dr. Berwick to the baby’s bedside for an exchange transfusion, a procedure now outdated because of better prenatal screening. She handed him a bag of blood, and he hung it on the IV holder and connected the stopcock. Syringe in hand, he began the transfusion. But something wasn’t right; the syringe felt sticky and he was pushing really hard. He just kept going.

And things got worse.

Within a few minutes, the baby was grey, mottled and squirming, and his heart rate was rising. Dr. Berwick paged the neonatal fellow on call and he arrived 20 minutes later, just as the lab results came back with the bad news: the baby’s hematocrit was 92. Dr. Berwick looked to the blood bag and followed a tube to the floor that was connected to a second bag filled with pure, clear plasma.

“I remember that moment; this flash of horror and tension seared in me,” Dr. Berwick says. He was transfusing with packed cells and the baby was going into acute renal failure. The neonatal fellow sprang into action and worked to reverse the damage.

Once the baby was stabilized, the fellow pulled Dr. Berwick aside and told him not to feel bad, that this could happen to anybody. But he had been taught to take ownership in his patients, and racked with guilt the young doctor went back to his on-call room and cried.

For 30 years, Dr. Berwick stayed silent on this story. He shared it on October 17 to set the stage for a summit of more than 300 thought leaders from physician practices and hospitals around the state as they participated in the second annual Patient Safety Congress hosted by the Colorado Medical Society and the Colorado Hospital
Association.

Dr. Berwick reflected on that experience, telling attendees that he didn’t go to the blood bank to report on himself. He didn’t go to the head of the training program to tell them he had moved between two different hospitals that used different banking procedures.
And he didn’t sit down with his fellow residents, tell them the story, and warn them about how it could happen to any one of them, too.

“We have a problem here,” Dr. Berwick told the audience. “The problem is ethical. Something went wrong that was highly preventable and we did nothing except fix the baby. There’s a better way to do this. We’re going to show you [today] that this isn’t just a matter of science or diligence; it’s a matter of ethics. To allow a person to be hurt in our hands without action is unethical.”

To achieve real success in-patient safety initiatives, Dr. Berwick explained, each health care professional on every level of the system must actively support a culture of safety. Physicians and nurses don’t intend to make errors. Errors inherently exist in the system because of the “human factor,” which is multiplied by the shear number of exposures over a patient’s entire care episode. When errors occur, the key is not to inflict punishment, regulation or blame, but to create systems of reporting and communication by which processes can be enhanced and improved.

“Every system is perfectly designed to get the results it gets,” he says. “The trick in safety, accuracy and reliability is to build a new system with new properties. … The concept that we can eliminate error is impossible. What we can do is build fortifications around it and construct robust systems.”

Vinod K. Sahney, Ph.D., another speaker at the Patient Safety Congress, told the audience that the current health care system is unreliable because “we rely on vigilance and hard work, we focus on outcomes rather than process, we fail to design and implement standard work, we do not learn from human factors, and we value individual freedom over reliable design.” Sahney served for 25 years as senior vice president at the Henry Ford Health System, which has become a leader in the patient safety movement because of its “No Harm Campaign” and the system-wide results it has achieved in harm reduction.

“We need to shift from a care delivery process dependent on autonomy to one centered on standardization,” Sahney says. “When we think about fixing errors, we think about not making mistakes. We have to design the systems that catch mistakes. You have to have checks and balances that catch them before they happen.”

To get physicians on board, you must frame the quality challenge in terms that are important to physicians. “Focus on improving the process to improve quality. Take wasteful things out…. Measure and display the results on important things and show [physicians] that together you’re making things better. Then they become champions in quality improvement,” Sahney says.

Leading into the congress, CMS surveyed physicians who work in a hospital setting on patient safety. CHA conducted a similar survey with a group of hospital executives. Results show that overall; physicians and hospital leaders feel that current patient safety efforts are effective.

However, physician respondents expressed the need to build systems of communication that emphasize evidence-based approaches and improvements to specific initiatives, a non-punitive culture that emphasizes education and communication of misses and near misses, and visible physician leadership guiding patient safety initiatives.

CMS has been on the forefront of the movement to retool patient safety systems for years; patient safety and professional accountability is one of the association’s five strategic priorities. Guiding the effort is the CMS Ad Hoc Workgroup on Patient Safety and Professional Accountability, formed four years ago to make policy recommendations and shape legislative strategies. It comprises physicians from around the state, legal experts, patient safety advocates and hospital representatives.

CMS past president Ben Vernon, MD, a transplant surgeon in Denver, is the current co-chair of the group and attended the Patient Safety Congress.

He says conferences like this present a great opportunity. “Today we had in the room a great mixture of hospital executives, patient safety officers and physicians listening to world experts on patient safety and the coming transformation in American medicine.
We [physicians] are not going to get this accomplished by ourselves. Physicians are not the sole standard bearers for patient safety, nor are hospitals, nor are nurses. We’ve got to do this together.

“So sitting everybody in the room to hear this information together, to laugh, to think and then to be challenged is really a big first step in the right direction and I’m looking forward to the results of this.”

CMS CEO Alfred Gilchrist agrees, and adds that the partnership with CHA to host this conference demonstrates the will of physician leaders and hospital executives to move forward. “We have to find a way to build on the energy from this meeting. We need more physician leadership and we need to put a greater focus on this collaboration. We’re anticipating a lot of great dialogue as we chart our future course, and I look forward to improved collaborations on patient safety.”

“ One of the things I respect most in the medical profession is the culture of learning and sharing and we can use this culture to make Colorado the safest state in the country to receive care,” Gilchrist says.

Multiple times throughout the day, Dr. Berwick praised the efforts of physicians and hospital executives in Colorado, recognizing the state as being far ahead of other states on patient safety initiatives. He encouraged stakeholders to keep pushing forward. “Though you are focusing on safety, I think you’re building to address the other dimensions of quality. There are players in Colorado that are ahead of the game. You’re doing something terrific in your ability to improve, not just in safety.”

“Bravo safety; it’s a great way to start, but it’s not the end. Colorado can cut its teeth and go to total excellence through the window of safety.”