When will Paul O’Neill receive the recognition he deserves?
Many years ago I left my office to meet the Vice President of Medical Affairs down the hall and in his office. As my door swung open, I noticed the Risk Manager talking with one of our more prominent orthopedic surgeons. I had no idea what they were talking about, but whatever it was, they both seemed very concerned.
Later that day I found out. The Risk Manager requested that he see me on an urgent basis. He informed me that the orthopedic surgeon had reported to him that he had operated on a patient’s knee . . . the wrong knee. How could this possibly have happened? The orthopedic surgeon in relating the mistake told the Risk Manager that, “He just could not understand how it happened; he could not remember what he was thinking about?”
Somewhere in his confusion is the answer. He should have been thinking about one thing . . . operating on the correct knee.
We live in a world that celebrates “multi-tasking.” We can drive a car, talk on the phone, listen to music, comb our hair and play a harmonica all at the same time. Physicians and nurses are human beings, with busy lives and lots of things to think about. They care about their patients and are mortified when they make a mistake. When you accidentally spill a cup of coffee on your host’s carpeting, an apology is usually good enough. When a patient accidentally dies due to a medical error, an apology is normally not enough to satisfy the grieving family. A national consensus within healthcare has developed that we can do a better job . . . a lot better. To see the American Hospital Association touting a program to save 100,000 lives would surprise many people in the general public.
At the root of the extraordinary increase in medical errors is the reality that the number of things we can do to patients has expanded much more rapidly than our safety systems. When one considers the history of aviation, there was a time when airplanes would get thrown together by “barnstormers,” and they would race in a primitive form of “Nascar in the sky.” Accidents were routine. A friend of mine who is a private pilot has opined that if automobiles were regulated as closely as airplanes there would never be an automobile accident due to mechanical error. The Federal Aviation Agency keeps a file on every airplane ever licensed and a record on every part that fails. If a pattern of failure is observed, a plan of correction is developed and mandatorily deployed in the aviation community. Still, we have airplane accidents. They are almost always attributed to “pilot error.”
Medical mistakes are almost always “pilot error.” The consequences in aviation are almost always fatal to the pilot. The consequences of medical errors on physicians and nurses will haunt them for the rest of their lives. Insult to injury is the grief that loved ones feel in the aftermath of a medical error discharged against a member of their family and the associated injury or death.
I am not unfamiliar with commercial aviation. Today is July 1. Since January 1, I have flown 67 commercial flights. I know the routine well. What if it were modified in the following manner? When approaching the gate agent, you are taken aside and asked to sign a multi-paged “consent form” moments before boarding the aircraft. You ask the gate agent what this is about; and he says, “Well, everyone signs these consent forms. By flying on our airplane there is a chance you will be killed or injured. If you are killed or injured, this consent form will absolve the airline from any liability, and you will waive all of your rights and the rights of your family to seek any legal redress. Everyone signs these, and you cannot fly until you sign this form.” You think about this for a moment and then ask, “How risky is this flight?” The gate agent says, “Well, since 1999, there is a consensus in the airline industry that we kill 98,000 passengers annually. We have no idea how many we injure.” You think for a moment and ask, “How many passengers did you kill or injure last year?” He says, “Well, that data is hard to get, and by the time we get the data, it will be about eighteen months old. But, I have some good news! The Association that represents all airline carriers has a campaign to reduce the number of accidental deaths by 90,000 this year. See, I’m wearing one of the buttons as a part of the campaign.” This scenario is so absurd it is hard to take seriously. It is an accurate reflection of where the hospital industry finds itself today.
There are two sides of this issue. One is not so nice. The fact is that the American hospital and the healthcare delivery system, in general, are danger zones. Trying to sugar coat this reality is misguided and unwise. Just as exquisitely engineered multi-million dollar airplanes fall out of the sky as a consequence of "pilot error,” hapless citizens will enter the healthcare delivery system and will be injured or die. The problem as described by knowledgeable observers of the healthcare industry is that it happens too often. We don’t have to save 100,000 people annually from flying in airplanes. Far more people fly each year than are admitted to U.S. hospitals, but we are trying to save 100,000 patient lives from the consequences of interacting with U.S. hospitals.
The second reality, and a lot more optimistic, is we can do a better job and there is a lot we can learn from the aviation community. To avert “pilot error” there are many checks and balances before an airplane leaves the ground. There are checklists that go over hundreds of mundane issues seeking to assure that all aircraft systems are operating properly. None of these tasks are intellectually challenging, but each one must be checked each time an aircraft flies. In contrast, there are fewer such systems in the American hospital. They exist, but it is often considered unnecessary, an insult to healthcare professionals and frequently ignored. One only has to remember the girl who died at Duke University Medical Center because someone failed to follow the “checklist” with respect to checking if her blood type was the same as the donated heart offered for transplant. As a consequence, a sequence of adverse events went into a tail spin, and the young girl died several weeks later. This was an accident that could have been averted.
Like pilots, physicians and nurses have busy lives that involve a lot more than flying airplanes or taking care of patients. The whole system has to be slowed down to make sure that the mundane details are checked and double-checked. It is annoying and time consuming. It has to be done, and it can be done. The work of Paul O’Neill and the Pittsburgh Regional Healthcare Initiative has demonstrated that when physicians and nurses accept this reality they can make an enormous difference.
A related, but equally important, reality is that the American hospital does not enjoy two realities we find in the aviation community; i.e., training and well engineered systems.
As I crisscross the country flying from client to client, I often overhear pilots talking about the need to get their mandatory re-training completed. It is a cost of doing business that is embedded in the aviation business, if you will. The re-education and training of physicians is woefully underfunded and poorly regulated. Hospitals, under cost pressures, have gutted education and in-service education programs to their nurses, other caregivers and employees, in general.
Is it any wonder that patients are frequently the “grist on the mill” of hospitals in which shortcuts are taken, physicians do not receive appropriate continuing education, nurses and others do not receive ongoing education and training and the hospital systems are thrown together by dilettantes?
While it is true that “bad things happen to good people,” it is equally true that “good people do bad things to good people” in the American healthcare delivery system.
Our firm does not have the expertise to make a difference in this area. We do not try. We are not qualified. We refer such business to others. One of the leading firms in this area frequently turns us away because they are simply too busy to take on another hospital client. They have another reason for turning business away. Believe it or not, they still find many hospitals leaders who “just don’t get it.” Not shared from a religious or spiritual point of view, Jesus said at the Sermon on the Mount, “. . . cast not your pearls before swine.” The unnamed consulting firm would rather “gargle with ground glass” than spend their time working with hospital leaders, physicians and other caregivers who are still in denial about the opportunities for patient safety. Worse, some healthcare leaders do "get it" but are not prepared to invest the will, energy, drive and "stick out their neck qualities" necessary to get their organizations on a new and improved pathway to success.
In time, ignorance will be exposed to light, and we will remember this as the “transition era in patient safety.” One hundred years ago, Dr. Abraham Flexner exposed the healthcare education industry to the “light” that medical education could be performed better . . . much better. At the time he was despised for stirring the pot. One hundred years from now, Paul O’Neill will be remembered for speaking “truth to power” and exposing the healthcare industry for performing well below its capabilities. We can only hope his dream for an error-free healthcare delivery system will occur during his lifetime.
Jan Jennings
Republished with permission from the Hospital News Group
No comments:
Post a Comment