Louisville Medicine Volume 67, Issue 11 - Page 6

WHY HOSPITALS SHOULD FLY AND THE NEED FOR IMPROVING PATIENT SAFETY “We are guests in our patients’ lives.” -Dr. Donald Berwick “Safety isn’t expensive, it’s priceless.” -Unknown A few months ago, I read an article in the Courier Journal about a patient that died in a local rehabilitation facility. His untimely death was a result of a series of preventable mistakes, including a serious omission of intravenous antibiotics. I was aghast as I read the article. This hit too close to home. How could this conceivably happen in our community with its apparent legacy of excellent care? When I started looking into this subject more deeply, I discovered some very alarming statistics. Despite sophisticated technology, precautions and good intentions, the death rate from medical errors is estimated to be over 250,000 annually in the US which makes medical errors the third most common cause of death behind heart disease and cancer. These numbers are equivalent to two jumbo jet crashes every day! When we evaluate the performance of our hospitals, we rely on safety scores from the national nonprofit organization named The Leapfrog Group (Leapfrog). Leapfrog provides safety ratings for more than 2,500 general hospitals in the US assigning A, B, C, D and F grades to hospitals based on their ability to prevent errors, injuries and infections. Since 2014 when Leapfrog implemented this grading system, they have noted improvement in all 15 of their “process” measures such as hand hygiene and physician staffing in intensive care units. However, Leapfrog notes that there has been a lack of progress in outcomes, with hospitals even declining on certain measures, such as preventing surgical site infections in patients who have undergone major colon surgery. Many of us are aware of how some of our local hospitals have received poor grades with Leapfrog’s patient safety metrics, including the safe administration of medications, the prevalence of thrombotic 4 LOUISVILLE MEDICINE events, and urinary tract and Clostridium difficile infections. Aside from the Leapfrog or other similar “health-grade” groups, there are numerous quality and safety-oriented organizations such as the Agency for Healthcare Research and Quality (AHRQ), the Institute for Healthcare Improvement (IHI) and the Patient- Centered Outcomes Research Institute (PCORI) that include patient safety and improved patient outcomes in their guiding principles. How are we to improve our outcomes and reduce the errors that are causing over 1,000 deaths daily in our hospitals? One way is to apply the lessons learned in the aviation industry as a model for patient safety, as suggested by John Nance in his 2008 book “Why Hospitals Should Fly-The Ultimate Flight Plan to Patient Safety and Quality Care.” While this book may seem a bit dated, the way he parallels the improvements that have been made in aviation to what needs to be implemented to improve patient safety are timely today. He describes the sentinel event that led to cultural change in aviation, the 1977 Tenerife accident. In that incident, a KLM jumbo jet attempting to take off crashed into a Pan Am jumbo jet that had not yet cleared the runway, resulting in 583 deaths. It was found after the tragedy that two crew members had concerns about the attempted takeoff but both acquiesced to the captain’s wishes to proceed. The changes that occurred in aviation over the next decade included focusing on the systems for safety, development of better crew resources, and removing the powerful hierarchical structure in the cockpit. This particular change helped mold a totally new culture of safety and teamwork in which all parties in flight had equal voice. In his book, Mr. Nance creates a fictional hospital, St. Michael’s, which follows best practices to create an environment in which all the lessons learned from aviation are applied to healthcare, changing the culture to