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.”

Hospitals devote a lot of attention to patient safety, but they have only begun to think about how patients can participate in their own safety.  Many mistakes involving medication, for example, could be prevented if communication between patients and doctors were improved.  Problems arise either when doctors prescribe the wrong drugs or when patients misunderstand instructions.  The physician should know what medications each new patient has been taking, and the patient should leave the hospital knowing exactly what medications to take. 

Keeping track of medications takes time, but new technology is making this process easier.  At Massachusetts General Hospital, an electronic medication list is created for each new patient, and the list is changed as new drugs are prescribed. 

Patients must also understand what their responsibilities are.  One study suggests that 77 % of patients are discharged from the hospital with inadequate medication instructions, often because doctors are under intense time pressure and feel isolated from negative consequences.  Another major problem is that 90 million Americans (almost one in two adults) lack knowledge needed to understand information pertaining to their health.  To improve patient-physician communication, many hospitals now use internet portals to allow patients to interact with physicians online.  Health illiteracy is a more difficult problem, and to address it, hospitals should seek patient input as to what technology will help them be more involved in their care. 

   

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