To err is still human: five years after the IOM report
A 2004 survey of more than 2,000 adults found that five years after the landmark Institute of Medicine Report, "To Err is Human"—which estimated that as many as 98,000 people die each year as a result of medical error—Americans don't think health care has gotten any safer. In fact, the results of the survey, conducted by the Henry J. Kaiser Family Foundation, the U.S. Agency for Healthcare Research and Quality and the Harvard School of Public Health, are a little disheartening: 55 percent of respondents said they are currently dissatisfied with the quality of health care in the U.S.
(up from 44 percent in 2001), 40 percent believe the quality of health care has gotten worse in the past five years and one-third reported a personal or family experience with medical error.
So what is Children's Hospital Boston doing about patient safety and
the quality of the care we provide to thousands of children every day? Quite a lot, as it turns out. Here, Children's News takes a look at three
of the hospital's latest efforts.
A suite way to simulate an emergency
The defibrillator is real. So are the ventilator and vital-signs monitor. A code cart stands ready with medications. Real oxygen flows through the tubes and pumps. And the tension in the crowded room is teeth-grindingly real. In fact, the only thing that isn't real in the Simulator Suite is the patient.
The residents, fellows, critical care nurses and respiratory therapist are responding to a mock Code Blue, where a boy-sized mannequin has an irregular heartbeat, faint but palpable pulse, dilated left pupil and a difficult-to-ventilate airway.
Three unseen video cameras record the resuscitation's progress. In a control room, Simulator Program Coordinator Liana Stanley, MEd, edits the scene on the fly, "voices" the boy and reprograms a computer to add new twists to his clinical condition. Later, the clinicians watch the videotape and discuss what went well and what didn't. Non-judgmental, constructive feedback is the rule.
"You watch yourself on the video taking forever to reach the right decision," says senior resident Jennifer Noon, MD. "It's kind of agonizing, but the next time you'll get to that decision faster."
Now in its third year, the fully-equipped Simulator Suite is one of the nation's first based at a pediatric hospital, and is used to train critical care providers throughout Children's Hospital Boston. It gives clinicians a chance to practice not just technical skills, but their ability to organize as a team in the face of a crisis, assign tasks and communicate effectively. In one scenario, for example, a senior physician gives an inappropriate command. During the debriefing, team members are asked what they were thinking, and why the command went unchallenged.
The lessons learned here are not soon forgotten.
"The material gets imprinted on the mind far more effectively than when we sit around the table with them saying, ’ÄòOkay, guys, don't forget to do this'," says Jeff Burns, MD, MPH, co-director of the Simulator Program. "There's no question our emergency preparedness is better."
The new voice of patient safety at Children's
Kathy Jenkins, MD, MPH, has been named director of Children's Hospital Boston's Program for Patient Safety and Quality, following a lengthy national search.
A long-time member of the Children's family, Jenkins has led the Data Collection and Auditing Committee for the past year, and also serves as chair of the Cardiovascular Program Scientific Review Committee.
"This is a very exciting time for the hospital. Dr. Jenkins will guide us to the next level in our quest to provide the highest quality care and service to our patients," says James Mandell, MD, Children's president and CEO. "We look forward to building on past successes and to the new opportunities for improvement that she'll lead."
The newly established Program for Patient Safety and Quality will pursue excellence in care delivery and improve the safety of our clinical services, research and training, combining existing efforts within the institution. It will also recruit faculty to participate in the new initiatives related to communication, education and measurement and also oversee all risk management and health care related regulatory activities.
Partnering with pilots for patient safety
As chair of the American College of Surgeons' (ACS) Patient Safety Committee, Children's Hospital Boston's Otolaryngologist-in-Chief Gerald Healy, MD, is well-versed in how to improve the quality and safety of patient care. "The operating room is already a place where clinical teams really come together," says Healy. "But as the complexity of cases continues to increase, the committee decided to look into additional opportunities to ensure the safety of patients in the operative setting."
So for inspiration the ACS looked outside the OR. They determined that the airline industry has been leading the idea of team training, or crew resource management (CRM), for the past 20 years, and the gold standard is United Airlines. They then learned of a group called Mach One Leadership’ÄîUnited Airlines pilots who conduct team training. "Mach One is the best of the best," says Healy. "So the ACS partnered with them to begin structuring a health care provider team training program."
This year, Healy volunteered Children's department of Otolaryngology to host a trial of the project. For the first phase of the training, Otolaryngology was divided into two groups’Äîeach one undergoing an introduction to CRM and its principles, including open communication, conflict resolution and error management.
Mach One trainers then spent a few days in the clinic and the operating room to observe how things run in Otolaryngology, and offered feedback on what things already worked well and what things needed improvement. "It's incredible how perceptive they were," says Healy.
Mach One has since identified four focus groups comprised of key players in various areas of the department who will look at areas for improvement and make recommendations for change. "Our goal is to help health care providers create a strong and self-sustaining culture of patient safety," says Greg Madonna, president and CEO of Mach One Leadership.
The third and final phase of training, which is further down the road, will be a "train the trainer" session to empower Otolaryngology team members to conduct trainings themselves.
In the meantime, several key changes have already been implemented including a daily morning team meeting with representatives from all providers and support staff. "It's really just a five-minute meeting to make sure we're all on the same page," says Healy. "But it's really empowered people to know that they have an important role to play and a chance to voice their concerns. I personally don't want adverse outcomes to occur because someone didn't speak up and challenge me or anyone else on the Otolaryngology team."
