Hospitals should be a haven. A place where injured people can have their wounds tended to and sick people can get well. U.S. hospitals succeed at meeting those goals most of the time, but that doesnt mean mistakes dont happen.
The highest scientific body in the U.S. The Institute of Medicine estimated that nearly 100,000 people annually more than the people who die from motor vehicle and air crashes, poisonings, falls and drownings combined die preventable deaths in US hospitals. Factor in the number of near misses such as a medication error caught just before the patient receives it and the number is estimated to grow to one million near misses every year.
“We need to create a safe space for hospitals and physicians to learn from these near-misses,” said Paul Barach, M.D., M.P.H., a national leader in patient safety and medical simulation, and the medical director of the Miami Patient Safety Center at the University of Miami/Jackson Memorial Medical Center.
To that end, Dr. Barach was part of an interdisciplinary commission that led a statewide effort to develop the most comprehensive patient safety legislation in the U.S., in the state of Florida. The result, which received overwhelming support in both the Florida House and Senate in May and was signed into law by Gov. Jeb Bush on June 9.
“This (legislation) allows us to walk back together from the brink,” he said. “There are three main parts. First, it creates a patient safety corporation that will have private access to all state data on preventable harm and near misses, and while this information will be available to the public, identification information of particular hospitals and practitioners will not be. Second, it requires hospitals to report every near miss. There previously had been no mechanism to capture theses near misses, which are ten to 100-fold more common than preventable deaths. Third, it requires publishing widespread hospital indicators starting with pneumonia and infection rates.”
This transparency in sharing information about mistakes and near misses is unprecedented, at least in the health care industry.
“Its modelled after the aviation safety reporting system,” said Paul Gluck, M.D., board chair of the Health Council of South Florida, Inc. and a gynecologist and partner of Vital M.D., Inc. “There is no recrimination because there is an understanding that in most cases it is not one persons fault, but a system failure.”
But even sharing the blame within a system is little comfort for an industry where the first thought following a mishap often concerns limiting liability.
“There is a lack of transparency in the (current) system which increases risk tremendously,” said Dr. Barach, who also cited problems such as a lack of access to records between hospitals and physicians, geographic barriers, insurance and regulatory requirements, and even new technology. “New gadgets increase the complexity of the system because the various technologies dont necessarily speak to each other.”
But even when the technologies become integrated, there still may be a failure to communicate.
“Sometimes technology has brought doctors away from the bedside,” agreed Dr. Gluck. “There are efforts underway in medical education to teach the importance of just sitting down and listening to your patient.”
And really listening to the patient becomes extremely important as the population ages but especially in diverse populations such as in south Florida.
“Language and cultural issues are extremely important in this area and in most parts of the country,” said Max Rothman, J.D., L.L.M., the executive director of the Center on Aging at Florida International University and the current treasurer and chair-elect of the Health Council. “In an era of high tech, health care professionals must recognize the importance of high touch. Communication is critical, particularly with an older population.”
Dr. Gluck says communication can be improved with more education not only for the caregiver but also for the patient.
“There is no question that a patient who is engaged in his or her own care has better outcomes,” said Dr. Gluck. “The Joint Commission has a pamphlet titled Speak Up. It teaches patients what questions they should ask of their caregivers.”
The questions in “Speak Up” are as simple as “why are you doing this?” or “what is this for?” And taking the time to answer questions posed by patients is not only a way to improve communication, but also a means to double check medications and avoid any potential errors.
“A lot of this stuff isnt rocket science,” Dr. Gluck says. “Its really common sense if you think about it.”
Dr. Barach says a little bit of common sense will beat more regulations every time. “We have many more regulations than we used to, but Im not sure if we have better safety,” he said. “We dont need more regulations. We need less but smarter regulations.”
But thats the rub. While other states have funded patient safety measures that are not as comprehensive as the new Florida legislation for multiple years and multi-millions, Florida has earmarked only $650,000 for a single year. Dr. Barach calls this “less than optimal,” but he and the other supporters are committed to making the best of the situation.
And the Health Council has a role to play too. Dr. Gluck says he sees the Health Council helping to educate and analyze data. Rothman concurs.
“The Health Council will continue to inform health care professionals and the general community about best practices in injury and infection prevention,” he said. “There must be full public disclosure of these issues, including data from institutions across the community. Everyone must understand that prevention of patient injuries and infections is a community priority.”
Sonya Albury, M.S.W., the executive director of the Health Council, seconds those thoughts.
“Community partners can help spread the word on how to engage patients and providers in improved dialog about their care,” she said. “We are committed to articulating strategies and interventions that can effectuate positive and measurable change so that everyone gains.”