When searching in pubmed for the two mesh terms “patient safety” and “medical education” results in 8 hits. Some research articles and editorials. One quote with literature reference about the extend of the problem is:
Our health care system today has an adverse event rate approximately equal to that of driving an automobile putting patients at a significant risk
The trouble as stated in this excellent editorial in Academic Medicine is the culture in which most health care professional work. Unfortunately working in a health care setting is mostly not about preventing errors or finding solutions to errors as in other sorts of organizations such as with airliner pilots or the military. In those organizations errors are part of their work. They are all expected to be part of the solution to errors than part of the problem. We in health care should also be a part of the solution and put all efforts to achieve succes in fighting against and preventing errors.
Medical education should be the place to start with teaching about the subjects of patient safety.
Research about patient safety is mostly done on procedures such as placing bloodstream catheters in Intensive Care Units. Simulation-based training reduces medical error, enhances clinical outcomes, and reduces the cost of clinical care. Examples in medicine for simulation based training are: laparoscopic surgery, anesthesiology with wireless machines that can blink, breathe, and simulate a plethora of medical illnesses.
It is absolutely the time for physicians, hospital managers, policy makers, patients, and the public alike to demand resources for the development of simulation centers that house modern equipment, with expert faculty to train the physicians of today. These processes must be integrated into the structure of current medical curricula, in order to achieve the highest possible outcomes for our patients.
More applications are on their way with progressing technical possibilities. There’s even a website for the Advanced Initiatives in Medical Simulation. It’s a lobbying coalition of individuals, organizations, and companies who wish to promote medical simulation in order to enhance patient safety, with concomitant error and cost reduction.
Health professions education efforts must require critical safety-related competencies and assess students’ safety knowledge, skills, and behaviors with as much fervor as their knowledge of the Krebs cycle and their ability to determine the differential diagnosis of weight loss.
These elemaents should be in the formal curricula. Every team member should be responsible for patient safety and hierarchie should be leveled. What do you think?
Wagner, D., Noel, M., Barry, H., & Reznich, C. (2011). Safe Expectations Academic Medicine, 86 (11) DOI: 10.1097/ACM.0b013e3182327c81
Aggarwal, R., & Darzi, A. (2011). Simulation to Enhance Patient Safety: Why Aren’t We There Yet? Chest, 140 (4), 854-858 DOI: 10.1378/chest.11-0728
Teaching patient safety starts in medical school. Hospitals can be weired chaotic places. It’s often a wonder everything keeps working as it should although failures do occur. Medical professionals come to realize that mistakes happen and they adapt their working procedures to those of the so called high reliability organizations such as aircrafts, airline pilots, forest firefighting teams and trauma centers.
This change in mostly culture doesn’t go swiftly mostly with the excuse that their work is different from those organizations mentioned. Their work is incomparable to other organization which is not true, moreover some principles can easily be adapted to also work in health organizations such as hospitals.
Much work has to be done, but starting teaching about patient safety during medical education surely increases patient safety in the future.
Principles from high reliability organizations are:
- Preoccupation with failures. Not only the big ones but also the small ones. These are often ignored and disregarded as variance.
Consider the following: stretchers used for patient transport can occasionally have stuck wheels. Initially, this does not really affect the department as a whole because there are many stretchers. But if not addressed, the lack of stretchers over time can paralyze a department at the worst possible moment.
Near misses are of much importance and response to these near failures often account for the culture of quality
- Reluctance to oversimplify. Oversimplifying e.g. an X ray request with the drop down menu “Chest pain” can lead to clinical problems.
With each cause of chest pain, there are different associations and recommendations that need to be made. Yet unless additional clinical points are also added to the requisition, the radiologist cannot render a more directed opinion.
- Sensitivity to operation. Being aware of what is written down in standard operating procedures and what is done in real life can be two very different things. Organizations should always look for these differences, not only be aware of them.
- Commitment to Resilience. Once a failure has happened, containing and limiting damage is required, and learning from mistakes is essential.
- Deference to Local Expertise.
In medicine, junior clinical or support staff members are frequently not comfortable voicing
their concerns about situations or may be ignored by more senior staff members. Understanding these dynamics and talking about roles in advance may reduce power distance and improve quality of care.
Prasanna, P., & Nagy, P. (2011). Learning From High-Reliability Organizations Journal of the American College of Radiology, 8 (10), 725-726 DOI: 10.1016/j.jacr.2011.06.020
Diagnostic errors are hot these days. this subject is of importance for patient safety and as such attention on this subject has increased. Previously I wrote about a diagnostic error, the availability bias. There are many more possible cognitive diagnostic errors to be made by physicians. Some diagnostic errors are more common in psychiatry.
Fundamental attribution error: the tendency to be judgmental and blame patients for their illnesses (dispositional causes) rather than examine the circumstances (situational factors) that might have been responsible. In particular, psychiatric patients, minorities, and other marginalized groups tend to suffer from this Cognitive Dispositions to Respond. Cultural differences exist in terms of the respective weights attributed to dispositional and situational causes.
Psych-out error : psychiatric patients appear to be particularly vulnerable to the Cognitive Dispositions to Respond described in this list and to other errors in their management, some of which may exacerbate their condition. They appear especially vulnerable to fundamental attribution error. In particular, comorbid medical conditions may be overlooked or minimized. A variant of psych-out error occurs when serious medical conditions (e.g., hypoxia, delirium, metabolic abnormalities, CNS infections, head injury) are misdiagnosed as psychiatric conditions.
Other cognitive diagnostic errors can also be present in psychiatry but these two are very recognizable, what do you think?
More cognitive diagnostic errors can be found in the excellent article of which these two come from.
Croskerry, P. (2003). The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them Academic Medicine, 78 (8), 775-780 DOI: 10.1097/00001888-200308000-00003