Improving Quality and Patient Safety

Three experts on medical safety offered their views on how hospital safety can be improved during the CIMIT Forum on Oct. 30 at the Simulation and Skills Center at Beth Israel Deaconess Medical Center.

Presenting were Ronald Newbower, PhD, strategic director and chief technology officer of CIMIT; Gregg S. Meyer, MD, MSc, senior vice president for quality and safety at Massachusetts General Hospital/MGPO; and Jeffrey Cooper, PhD, director, biomedical engineering, Partners HealthCare System, professor of anesthesia, Harvard Medical School; Department of Anesthesia and Critical Care, MGH.

At the heart of their discussion was the troubling statistic that in one recent year, up to 98,000 patients died in U.S. hospitals as the result of mistakes, some by receiving the wrong medication or an inappropriate dose of the right medicine.

Dr. Cooper spoke on the topic of “New Hazards of Medical Technology: Two Case Discussions.” He said that different systems in hospitals often don’t talk to each other. He outlined several real-life examples where patient safety was endangered because different computer systems were not combining to produce correct and essential information.

He urged listeners to make careful studies in operating rooms and special-care units when changes are made in hospital systems. The slightest differences in health-care operations can cause problems that can take months to correct.

Dr. Meyer spoke about “An Untapped Role for Patients: Online Reconciliation of Meds and Monitoring of Health Care Transitions.”

He said that consumers and medical professionals must continue to ask questions and seek improvements if medical centers are going to increase their safety records.

“I sometimes think of a giant private company like Home Depot,” said Dr. Meyer. “They try very hard to correct problems, and they’ve taken on a culture of improvement. Everyone works to make their store a better operation, and the other stores nationally.
           
“It might take time to implement the correct procedures or ensure that a discharged patient is leaving with the correct medications, but it is really worth it, for hospital and patient.”

Dr. Newbower spoke on the topic of “How to Protect Oneself from Injury by Human Error.”

In the past, medical devices were largely based on hardware and usually failed one at a time.  Today, most medical devices involve complicated software and tend to fail all at once.  As the interconnectivity of medical technology grows, healthcare providers must ensure that a system crash will not pose a danger to patients.  Medical technology for the future should be designed so as to avoid problems that have occurred in the past.

In October 2006, one hospital’s ECG system, which was connected to its admission system and its billing system, was hit by a virus because the manufacturer had been slow to send out needed patches.  The system became unstable, and for six weeks, as engineers tried to rebuild the system, it was difficult for doctors to access ECG information.  The engineers eventually decided to upgrade the system’s operating system.  The old database of user information, however, was not compatible with the new version of Windows, so it was still tough for doctors to access ECG data.  Other bugs took over a year to resolve, and although no patients were harmed, the hospital lost a serious amount of money.    

A second type of problem is exemplified by a case involving infusion pumps used to deliver potent drugs.  A few years after the pumps were installed, the hospital decided to upgrade them in order to introduce safety features.  The upgrade proceeded smoothly, but a day later, eight of the 96 pumps failed.  The hospital was able to switch to other pumps without harming any patients.  But why had the pumps failed?  A little investigation revealed that some nurses using the upgraded pumps had tried a non-standard procedure that had worked on the pumps before the upgrade. 

As medical devices are integrated into large systems, hospitals must remember that in practice, devices must be compatible with older devices and that devices will not always be used as the instruction manual suggests.     

   

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