CIMIT FORUM
AGENDA
Simulation and
October 30, 2007
4:00 – 6:00 PM
Improving
Quality and Patient Safety
4:00PM How to Protect Oneself From
Injury by Human Error in a Hospital
Ronald Newbower, PhD, Strategic Director, CTO and
Chairman, Executive Committee, CIMIT; Faculty member, Harvard Medical School,
MIT, and Harvard-MIT Division of Health Sciences and Technology, Partners
HealthCare System, Inc., and Massachusetts General Hospital, rnewbower@partners.org
Every year,
100,000 people die in
People
should not go to the hospital needlessly and should seek a second opinion
before electing to undergo non-emergency surgery. When in the hospital, one should attempt to
have an advocate with him or her. The
advocate should be someone who can ask questions that the patient may be too sick
or too shy to ask for him or herself.
Patients must remember that they have a right to know the details of how
they are being treated.
The
riskiest moments for a patient occur during handoffs, when the patient is
passed from one caregiver to another, as doctors and nurses new to one’s case
can make mistakes. Infections are also a
hazard, for drug-resistant bacteria lurk in hospitals. A study conducted by the New England
Journal of Medicine showed that simple sanitary practices, such as regular
hand washing, can reduce infection rates to almost zero. Thanks to ongoing technical and educational
progress, patient safety is improving, but work remains to be done.
4:20PM An Untapped Role For Patients: Online
Reconciliation Of Meds And Monitoring Care Transitions
Gregg S. Meyer, MD, MSc,
Senior Vice President for Quality and Safety, MGH/MGPO, gmeyer@partners.org
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
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.
4:40PM New Hazards Of Medical Technology: Two Case
Discussions
Jeffrey B. Cooper, PhD, Director,
Biomedical Engineering, Partners HealthCare System, Inc.; Professor of
Anaesthesia, Harvard Medical School, Department of Anesthesia and Critical
Care, Massachusetts General Hospital, jcooper@partners.org
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.
This video is not available.
5:00PM Panel discussion