A recent study in the Journal of Patient Safety found that as many as 400,000 patients each year suffer some type of preventable harm in a hospital that contributes to their death. This, after 15 years of a supposed focus on improving hospital safety. Hospital groups have challenged the data, but the fact that we are debating whether we’ve made gains is a bad sign. Experts in a recent Senate hearing recommended that we continue to:
- Improve IT systems to minimize cognitive mistakes;
- Incentivize a focus on patient safety; and
- Implement reliable data, metrics and monitoring systems
Is this really the answer? We’ve been throwing technology and process solutions at the problem all of these 15 years. How bad is the problem?
- Over 100,000 adverse events occur in hospitals each day.
- Your risk of death by plane crash is 1 in 8 million but your risk of death because of an error during a hospital admission is 1 in 1,000!
What sort of errors are we talking about? :
- Diagnosis errors
- Misinterpretation of medical orders
- Medication errors including:
- Confusion between drugs with similar names
- Incorrect drug calculations
- Environmental conditions that distract providers
Think about these errors. Technology and process improvements can help but 80% of errors have a human element. Certainly, it’s often difficult to pinpoint the exact cause of an error. Errors in complex systems are nearly always multi-focal. I’ll say it again, though – 80% of errors are due to human error of some sort. In other industries, we’ve studied the correlation between behaviors and errors or accidents and established a strong connection and we hire and train with these behaviors in mind. It’s time to explore the connection to patient safety. The airline industry, for instance not only puts in checklists, but studies human behavior and trains flight crews, for instance on communication techniques.
Think about these types of errors and three very measurable behavioral competencies:
- Attention to detail
- Accountability (and the willingness to hold others accountable).
It’s not too big a leap to see the connection to individual behaviors when a nurse or physician fails to follow proven protocols or takes short cuts, isn’t clear about a medication or dosage, or simply mis-reads it without double checking, doesn’t ask enough questions or misses key data in making a diagnosis, fails occasionally to wash their hands, or somehow performs surgery on the wrong side of the body (it happens nearly 4,000 times a year!).
There are other psychological issues at play, (including stress tolerance, for instance) but these three are good starting point. Rarely is the error related to a gap in the provider’s clinical or technical knowledge, or thinking skills – it’s about these important behavioral competencies. Is the provider able and willing to take all the right steps, every time – or are they behaviorally inclined to make these errors?
Certainly we put processes in place to make it harder to make mistakes, but in the end, we have humans providing care in a complex environment. There are behavioral competencies that impact patient safety and it’s time to start making the connection and addressing it.