The healthcare sector is complex by nature. Physicians aren’t necessarily employed by hospitals, so the level of internal communication needed to generate better data is often not there. Since medical errors still rank as the third leading cause of death, with roughly 10 percent of deaths in the United States due to preventable medical mistakes each year [1], there’s certainly room for improvement. As reports confirm that patient experience and patient safety are directly linked, [2] hospitals must be focused on both to succeed in providing patient-centered care.

The military developed a behavioral approach to help teams sharpen their tactical awareness skills in combat to remain “left of bang,” or to fend off hostile actions before they culminate in the “bang” of conflict. Healthcare needs to deploy the same approach to managing risk and improving patient safety outcomes. Almost all of healthcare is focused on the “right of bang” approach, or the reactive correction of adverse events (Image 1). Everything is oriented to logistically and financially react to a problem that has already occurred. And as healthcare errors go unreported, hospitals often aren’t equipped to conduct apt investigations.

 

Image 1

 

Nationwide, forward-thinking healthcare organizations are starting to realize the importance of adopting solutions that allow them to stay “left of bang”. Data collection, over time, of traditionally siloed departments, allows hospitals and health systems to pinpoint at-risk processes, before an error can occur. This methodology aids to prevent and intervene in those situations heading towards a bad outcome or “bang.”

This movement, from an operational mode to a preventative approach is essential for the evolution of healthcare safety, especially as the industry continues to push towards value-based care. Hospitals have a pathway to achieving zero harm, but only if they connect data and develop effective tracking measures to ensure all safety issues are addressed in real time.

Health systems must evaluate the barriers employees face, in order to improve this process. In particular for medication error reporting, a study found that the extra time required in reporting and cumbersome report forms, deterred employees from “telling” someone. For every medication error reported, there were as many as 100 errors not reported or detected [3].

Identifying the hurdles that healthcare professionals face, is an important first step in improving medical errors. Organizational culture and system improvements deeply impact how errors are responded to by hospital management and how often front-line staff report errors in order to prevent future harm to patients. By planning and preparing for medical errors, organizations can reduce the frequency and severity of them happening in the first place, further driving their high reliability goals and preventing future patients from being harmed.

 

Resources:

[1] https://www.usnews.com/news/articles/2016-05-03/medical-errors-are-third-leading-cause-of-death-in-the-us

[2] https://www.fiercehealthcare.com/patient-engagement/press-ganey-report-links-safety-to-patient-experience

[3] https://www.pharmacytimes.com/contributor/alan-polnariev-pharmd-ms-cgp/2016/07/overcoming-obstacles-to-medication-error-reporting 

 

Recent Posts

Medical Errors – 20 years After To Err Is Human

One of the most referenced and influential reports on raising awareness of the patient safety crisis in the United States marked its 20th anniversary this fall. The Institute of Medicine released the groundbreaking 1999 report “To Err Is Human: Building a Safer Health System,” 20 years ago as rapid changes were occurring in the healthcare

Read more »
Workarounds in Healthcare

A recent New York Times op-ed offers that the prevalence of workarounds is an indication of the overall dysfunction of the American healthcare system, going as far as to indicate these workarounds are often a “trade-off in values” where providers must choose between onerous rules and patient safety. While workarounds are not ideal, we must

Read more »
There’s No Room for a Bad Attitude in the Surgical Suite

Why do doctors have such a reputation for being jerks? Is it the better surgeon they are, the bigger the ego? While this perception isn’t always true, dealing with a condescending doctor is something most of us have had to endure at one time or another. A recent study revealed what fellow clinicians have known

Read more »