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Veterans Health Administration


Playing It Safe

Group of medical professionals in a discussion</p>


This year, March 4-10 is being recognized as Patient Safety Awareness Week. But at the Department of Veterans Affairs, patient safety is Job One 52 weeks a year.

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.

The Distraction Factor

“Everyone makes mistakes, especially in a hectic, high stress environment with lots of distractions,” said Dr. Ann Polich, Associate Chief of Staff for Patient Safety at the VA Medical Center in Omaha, Neb. “And that description fits just about any hospital in the United States.”

Polich attended a VA patient safety workshop six years ago, took what she learned there and launched her own patient safety program at VA Omaha.

“That workshop was an eye-opener,” she said. “Before taking it, I’d been frustrated. I knew I could be providing better care to my patients…I just didn’t know how to go about it. But here’s what that workshop taught me: patient safety is effective if it makes it hard to do the wrong thing and easy to do the right thing. If the system makes it difficult to make a mistake, then it’s hard to inadvertently hurt someone.

“When confronted with an adverse event, health care needs to get away from the, ‘Who do we blame for this?’ reflex.”

— Doug Paull, National Center for Patient Safety

“Here’s an example,” she said. “If you choose not to wash your hands before you interact with a patient, that’s an administrative issue. But if you forget to wash your hands, it’s a process issue. Patient safety means implementing a process — such as a checklist — that prompts a person to wash their hands. Checklists, in fact, are a big part of patient safety at VA.

“I can’t tell you how easy it is to get distracted,” she added. “But if you have a system that automatically reminds you to follow correct procedure, it reduces your vulnerability to error. Let’s face it; anything that’s left to memory, a human will forget. Especially humans who are facing as many distractions as doctors and nurses are.”

But before you can build a better system, you need to know where your current system’s weak spots are. And you can’t know that unless your doctors and nurses are willing to report the errors they make while trying to deliver the best care possible to their patients.

That’s why the Department of Veterans Affairs is training 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 Blame Game

Dr. Doug Paull, Graduate Medical Education Patient Safety Curriculum Director at VA’s National Center for Patient Safety in Ann Arbor, Mich., 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?’ That’s root cause analysis in action. 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 ‘look alike’ vials that made it easy for the error to occur? Only the second approach prevents the incident from happening again.”

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. “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.

“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.”

That’s why 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.

On the Front Lines

“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.”

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 ‘frontlines’ — that is, 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.”