October 5, 2009

Preventing med errors: Avoid blame game, punish offenders

Patient safety experts at Johns Hopkins and elsewhere are taking their prescription for avoiding medical errors in hospital care one step beyond already successful “no fault, no blame” approaches, calling now for penalties for doctors and nurses who fail to comply with proven safety measures.

Penalties should apply, these experts say, only when current “no blame” practices designed to prevent recurrences stall, and after warnings and counseling have failed to change health care workers’ behavior.

“Our preference during the last decade for not assigning blame to individuals went a long way to encourage the disclosure of medical errors and getting buy-in for the idea that systemic safety problems existed and could be fixed,” said anesthesiologist Peter Pronovost, a patient safety expert at Johns Hopkins whose development of “medical checklists” has reformed and cut down on the number of wrong-site surgical errors and preventable bloodstream infections in hospital care worldwide.

“But despite making systems safer and counseling staff on best practices, mistakes continue to happen, so it’s time to add some accountability and enforcement policies to address and stop unsafe practices,” he said.

Pronovost makes his case, along with fellow patient safety expert Robert Wachter, of the University of California, San Francisco, in the issue of the New England Journal of Medicine online Oct. 1. The pair bases its call on the estimated 100,000 yearly deaths in the United States from infections picked up by people while undergoing treatment, most often in hospitals.

In their report, Pronovost and Wachter suggest penalties that they say could serve as a starting point for implementing an accountability system to run parallel to the “no blame” approach for four common but entirely avoidable medical errors.

Health care workers who persistently fail to wash their hands before entering a patient’s room, for example, would be required to undergo mandatory training and re-education classes, and lose their patient care privileges, with loss of pay, for a week. Repeated failings by surgeons to conduct a “time out” prior to surgery would result in retraining sessions and a loss of access to the operating room for two weeks, with a commensurate loss in pay. Repeated failure to use and sign surgical checklists when inserting catheters would be similarly punished.

To support their “get tough” approach, Pronovost and Wachter cite more than half a dozen examples in which the “no blame” approach has been successful only up to a certain point in correcting unsafe hospital practices and lowering the number of unintended mistakes in patient care.

Included in this list are computerized systems to reduce medication errors caused by doctors’ sloppy handwriting or by similar-looking drug packaging, requirements that surgeons mark the site of an operation and perform “timeouts” to double-check plans to stop wrong-site operations, and the placement of disinfectant hand-gel dispensers outside patient rooms to encourage rigorous hand hygiene.

Although such efforts have been largely successful in reducing errors, the experts say that problems continue, noting the 4,000 wrong-site surgeries that still occur each year.

Held up for particular scorn and example by the experts are persistent failures of hospital staff to follow mandatory hospital hand-washing policies. No more than 70 percent of health care workers, at best, routinely wash their hands before entering a patient’s hospital room.

Labeling those who habitually fail to comply with mandatory patient safety protocols “disruptive caregivers,” Pronovost and Wachter lay down eight principles to determine if punishments are warranted. Among them: Initial efforts must have been made to resolve underlying systemic problems that contribute to medical error, and re-training and counseling must have been tried.

According to Pronovost, who is also medical director of Johns Hopkins’ Center for Innovation in Quality Patient Care, finding the right balance between carrots and sticks will be hard work. He says that Wachter’s and his framework is meant to serve as a starting point for individual hospitals and other health care agencies to customize a system that suits their own circumstances.

“Above all else, physicians and other health care providers need to recognize that the main reason to find the right balance between no blame and individual accountability is that doing so will save lives,” Pronovost said.                         —David March