Preventing medical mistakes

    DelCo health system asks workers to speak up.

    Even in the fast-paced, complex world of medicine, some mistakes should never happen such as operating on the wrong body part. WHYY reports on a program that encourages hospital workers to speak up when they see that a mistake is about to happen.

    Listen: [audio:091127tesafety.mp3]

    Every hospital in Pennsylvania is required to report serious medical errors. In 2008, executives at Delaware County’s Crozer Keystone Health System decided to do more. Now, they also track averted mistakes.

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    Young: We said, you know, we don’t really know how close we come to it, because we don’t know when our staff catch these near misses.

    Eileen Young is an assistant vice president at Crozer Keystone. She says the surgery team took the initiative, not wanting to wait for a serious mistake to take action. Surgical staffers now get rewards and recognition when they report a near miss. Each near-miss report is called a Great Catch.

    It’s not about the negative of ‘Gee, who didn’t do something right.’ Most failures are system failures, not people failures.

    The culture in health care really has been that these things aren’t allowed to happen, and if they happened it must be somebody’s fault that this happened.

    Surgeon Eric Dobkin is vice president for patient safety at Crozer Keystone. He says preventable mistakes do happen, despite all kinds of safeguards and checklists.

    Medical facilities in Pennsylvania reported performing 76 wrong-site surgeries last year. Part of the problem, Dobkin says, is hospital tradition that shames and punishes workers.

    Dobkin: We want people to report more, to be open about it and have the courage or the ability or the willingness to speak up about what they may consider the most trivial things but may turn out to be life threatening if they reach a patient.

    Dobkin says the Great Catch program is changing the culture at Crozer Keystone, and that should make it easier to identify holes in the system.

    Maximillian Santiago directs surgical services at Taylor Hospital. He says the Great Catch program removes fears about reprisal or bullying from higher ups.

    Santiago: The old school method of education in the operating room was that people never challenged a physician. The new theory of thought is that we need to be more proactive in stepping in when there are situations where we believe patients care could be compromised.

    Patient safety and health care quality have gotten lots of attention in recent years. Hospital safety officers say they’re working to prevent a range of mistakes from medication errors to infections that patients acquire after they arrive in the hospital.

    Health payers are cracking down, too. The federal government and Pennsylvania now refuse to pay the added cost of treating patients injured by some preventable mistakes.

    Rieders: It’s all the rage in the medical community certainly among the administrators and the people who run hospitals, nevertheless, we have a lot of work left to do.

    Medical malpractice attorney Clifford Rieders worries that regulators lack the resources to monitor hospitals and enforce the new rules.

    Rieders serves on the Pennsylvania Patient Safety Authority. He says the other members recognize that botched surgeries and other mistakes cost money — as well as lives.

    Rieders says a hospital executive on the safety board recently pulled him aside.

    Rieders: And he said to me after one of the meetings. We make more money, we have less claims, things go more smoothly if we have more patient safety. It just makes for good business.

    Mary Ellen Mannix is a Delaware County mom. Her infant son died in 2001 after a surgery that included a series of medical errors. She’s unhappy that Pennsylvania’s patient safety board wasn’t set up to respond to the concerns of patients and families.

    Mannix: We should be able to create an 800 number with somebody on the other end who has responsibility to the constituents of Pennsylvania to make sure this information goes somewhere.

    Patient safety advocates are pushing lawmakers to make the issue a bigger part of the debate on how to fix health care. Right now, advocates say, it is rarely mentioned.

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