Residents are involved in providing much of the front line clinical care at VA hospitals and clinics.
VHA Patient Safety’s Goal: Fix the Problem!
In its 2000 report, “To Err is Human,” the Institute of Medicine estimated that medical errors cause between 44,000 and 98,000 preventable deaths each year in U.S. hospitals, and about one million injuries.
Interestingly, the majority of medical errors aren’t the result of incompetent people in health care, but competent people working in faulty health care systems, according to the report.
That’s why the Department of Veterans Affairs is telling young residents — tomorrow’s doctors — that it’s OK to report their mistakes and even their ‘near misses.’ At VA, mistakes are regarded as teachable moments and, consequently, an opportunity to improve the entire system.
“The physician must have two special objects in view with regard to disease, namely, to do good or to do no harm."
— Hippocratic Corpus
The Big Picture
“More than half the physicians-in-training in the United States do at least part of their medical school and residency training at VA medical centers,” explained Linda Williams, a Patient Safety Program Specialist with VA’s National Center for Patient Safety in Ann Arbor, Mich. “But during their time with VA, they’re not just learning how to diagnose and treat. They’re also learning how to prevent inadvertent harm from reaching their patients. They’re learning how to diagnose and treat ‘system ills’ that are part of every health care system on the planet.”
According to Williams, doctors must often deliver health care within a faulty system.
“But it’s difficult to imagine a physician having time to simply, sit down, and think about how to fix things that are wrong with the system,” she observed. “A problem arises, they deal with it, and move on. But improving patient safety means considering the bigger picture. When something goes wrong, it’s time to evaluate the system. Instead of moving on, you make sure the same thing doesn’t happen again. You fix the system.”
VA’s National Center for Patient Safety places a strong emphasis on teaching both residents and seasoned VA personnel how to recognize and address flaws in the health care delivery system.
“Our job — the job of the National Center for Patient Safety — is to promote a safe health care environment,” Williams said. “To accomplish that, we routinely conduct patient safety workshops for physicians-in-training and their teachers. Faculty attending these workshops are typically physicians and nurses who are both expert clinicians and expert teachers.”
On the Front Lines
Williams said she’s a big believer in the hands-on approach to teaching. “We prefer to integrate patient safety training into a resident’s day, rather than add to a resident’s already busy schedule with mandatory classes or lectures,” she explained.
By teaching VA doctors and nurses how to teach patient safety techniques to residents, VA hopes to improve patient safety on the ‘front lines’, at the patient’s bedside.
“The fact is, residents are involved in providing much of the front line clinical care at VA hospitals and clinics,” Williams explained. “So our goal is to teach these young people to be patient safety problem solvers. We’re also depending on our residents to influence others throughout their careers, regardless of whether they’re working for VA or private health care.”
The Sledge Hammer Approach
Williams said improving patient safety can be something as simple as taking a sledge hammer to a wall.
“Not too long ago we had a patient safety fellow who was part of a team analyzing a close call that had occurred in a VA emergency room,” Williams said. “She observed that in the emergency room waiting area, the patients were sitting where they couldn’t be easily seen by staff at the front desk. A wall was blocking their view of the patients. Sick people, waiting to be seen, were sitting where no one could monitor them. The team told the hospital they needed to ‘knock down that wall.’ And you know what? They did.”
When something like this occurs, VA’s National Center for Patient Safety can send a recommendation to all 152 VA medical centers, asking them to check their emergency room waiting areas to make sure the same thing isn’t happening. “VA’s integrated healthcare system allows all medical centers to benefit from ‘lessons learned,’ making it possible to fix systems before adverse events can occur,” Williams said.
The Blame Game
“Taking down the wall in the emergency room is a good example of a strong action,” said Dr. Doug Paull, Graduate Medical Education Patient Safety Curriculum Director at VA’s National Center for Patient Safety. “When you change the system, you’ve not only fixed it for your patients, you’ve fixed it for every patient.”
Paull said VA places a great deal of emphasis on teaching its residents the value of reporting adverse events and participating in the root cause analysis process. “When an adverse event occurs, it’s important to analyze what happened, and why it happened,” he said. “Residents have not traditionally been taught this ‘systems-approach’ towards medical error.”
He continued: “When confronted with an adverse event, health care needs to get away from the, ‘Who do we blame for this?’ reflex. Instead, we need to ask, ‘How did this happen and how do we prevent it from happening again?’ We need to abandon the blame-and-shame approach for errors that any of us could have committed under the same circumstances.
“For example,” he continued, “if a nurse gives the wrong strength of a blood-thinner to a patient because the two vials look alike, then what makes more sense … fire the nurse? Or fix the real problem — the lookalike vials that made it easy for the error to occur? Only the second approach prevents the incident from happening again.”