Tuesday, November 1, 2011

USA Today: Medicare Inspector General - "More tracking of serious errors needed"

Have to applaud this report since reporting and tracking are often the first steps towards improvement:

In an excerpt from the article - "That means that those hospitals ... don't learn from their mistakes, Inspector General Daniel Levinson writes .. No one tracks the effectiveness of policy changes or how the hospitals actually correct mistakes." 
These statements get at the real crux of the matter - serious adverse events are happening everyday throughout the nation's hospitals. However, are we learning and responding appropriately to the same in order to reduce the risk of injury for subsequent patients? 
In addition to reporting and tracking of the errors, we need robust risk mitigation and performance improvement systems to ensure that patient safety is being improved:
  • Root cause analysis of these events to get to the incipient causes of the errors.
  • Corrective action plans that hospitals are held accountable to in order to ensure that the root causes are mitigated.
  • Failure modes and effects analyses (FMEAs) to ensure that we understand all the myriad ways systems can fail.
  • Systems redesign to ensure that the culture, workflow, clinical actions, and behavior that led to the error are truly modified.
  • Auditing and Monitoring of systems and outcomes to ensure that the intended changes have gone into effect.
  • Real-time assessments of adverse events in order to mitigate immediate risk to the patient in front of us - in addition to retrospective analyses or prospective improvements.
As outlined above, many actions can be taken to improve patient safety. Unfortunately, as hospitals continue to be impacted by the recession - reductions in volumes, cut-backs in budgets, and cuts in reimbursement, patient safety staffing and patient safety systems are not as robust as they need to be.  We can mandate more monitoring, reporting, and tracking of errors, but unless we work with hospitals to develop the infrastructure required to build patient safety systems, patients will continue to be harmed by the very systems intended to help them.

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