Anything and everything that improves patient safety is important. The sheer weight of that sentence can be overwhelming to healthcare professionals. Consider one conclusion from the Institute of Medicine (IOM) report “Improving Diagnosis in Healthcare” that states, “Advancing patient safety requires an overarching shift from reactive, piecemeal interventions to a total systems approach to safety in which safety is systematic and is uniformly applied across the total process.” For those charged with fixing patient safety in their practice, hospital or health system, the words “total,” “systematic,” “uniform” and “process” are enough to induce panic followed by paralysis.
Achieving a system solution is a daunting ultra-marathon race, not a sprint. So while we pace ourselves for the long haul, a good question is to ask is if we should focus to make a more immediate impact, and if so, where. I suggest that the answer can be found somewhere between “Willie Sutton’s Rule” and the National Patient Safety Foundation (NPSF). Willie Sutton was a bank robber; when asked why he robbed banks, he responded, “Because that’s where the money is.” Willie Sutton’s Rule says that one should focus on obvious, high-yield activities instead of wasting time on less fruitful ones. In the absence of unlimited resources, this rule seems a wise one for patient safety initiatives in hospitals and healthcare systems, not just for bank robbers. Now, fold in the recommendation from the NPSF publication “Free from Harm” that says, “All healthcare stakeholders should recommit to and prioritize patient safety in general and the goal of eliminating harm to patients in particular.” Perhaps between Willie and the NPSF, the targets for immediate impact come into view – namely preventing the errors that harm patients the most.
I would submit that regardless of the patient care setting, the leadership team should focus initially on identifying the areas of greatest patient harm and prioritize the actions required to prevent those adverse outcomes. What is the biggest problem? Recurring errors with a single medication? One particular wrong-site surgery? The #1 healthcare-acquired infection in your hospital? A procedure with frequent complications? A commonly delayed or missed diagnosis? Existing data from incident reports, CMS reporting, medical records, and claims data can guide the prioritization, but chances are you already know the problem. The leadership and key stakeholders from existing committees and programs should be able pare down the extensive to-do list to 1 or 2 critical problems that harm patients, and then take a SWAT-team approach to eliminate those errors or threats.
The NPSF “Free from Harm” and the IOM “Improving Diagnosis” reports provide supporting data to help pinpoint what the problems are and where these high-frequency, high-severity harmful events are occurring. Consider the following statistics:
- Adverse Events: About 1 in 10 patients develops an adverse event during hospitalization such as a healthcare–acquired infection, a pressure ulcer, a preventable adverse drug event or a fall.
- Medication Errors: One in 2 surgeries had a medication error and/or an adverse drug event; additionally, more than 700,000 outpatients are treated in the emergency department every year for an adverse event caused by a medication—adverse events severe enough in 120,000 of these patients to require hospitalization.
- Diagnostic Errors: One in 20 adults who seek outpatient care each year experience a diagnostic error. Diagnostic errors contribute to approximately 10% of patient deaths, and they account for 6% to 17% of adverse events in hospitals. Diagnostic errors are the leading type of paid medical malpractice claims and are almost twice as likely to have resulted in the patient’s death compared to other claims.
Here is one example of where and how to focus to make an impact by reducing diagnostic error.
- Select a high-frequency, high-severity chief complaint or diagnosis that frequently results in patient harm when the diagnosis is delayed or missed (e.g., chest pain, abdominal pain, sepsis, or whatever you select). This may be a clinical problem in either the ambulatory or inpatient setting or both.
- Launch a performance improvement program that includes a specific education program for all staff and an assessment tool (such as chart audits) to measure baseline and ongoing improvements in clinical performance related to the selected chief complaint or diagnosis.
- Provide feedback early and often to clinicians while involving them at every level to develop and adopt evidence-based approaches to the evaluation and treatment of the problem complaint or diagnosis.
- Continue the cycle of education, assessment and feedback until the short-term goal of improvement is reached and then integrated into a sustainable and comprehensive patient safety program.
Don’t get me wrong here. In the long run, the comprehensive systems approach with unwavering leadership is the right route to sustainable success. Along the route, however, patients are still getting sick and dying from errors that can be prevented using a targeted approach. During the carefully planned and paced marathon event of patient safety, it is sometimes necessary to throw in an occasional sprint to get to the finish line. You can bet that if Willie Sutton were running this race, he would sprint right to where the money is.