During a respiratory emergency in the operating room, an anesthesiologist has only a few minutes to diagnose and fix the problem or the patient might die. If the patient's airway is obstructed, the anesthesiologist might use a flexible bronchoscope to intubate.
It's a difficult procedure to master, particularly in the hands of a nervous resident with little or no experience.
Using computer simulation, an anesthesia resident at Children's Hospital Oakland (Calif.) can master the bronchoscope before trying it in the operating room. The resident inserts the device--a long, flexible tube with a fiber-optic lens--into the nose of a robotic faceplate. A computer screen displays what the resident would see inside a real patient's lungs. The resident then snakes the spaghetti-like tube through the virtual patient's airway.
"It's like using chopsticks for the first time," says staff anesthesiologist Richard Rowe, M.D. But after 10 to 20 procedures, most residents develop the motor skills needed to work on a real patient, Rowe says. And no life-threatening medical errors are made in the process.
Medical errors in U.S. hospitals became front-page news last November when the Institute of Medicine released a report estimating that such mistakes kill between 44,000 and 98,000 patients each year and result in annual costs of $38 billion to $50 billion. Public outrage over the report resounded on Capitol Hill and in healthcare organization boardrooms. Members of Congress are trying to craft a patient safety bill and are holding hearings to examine current laws, and healthcare organizations are assembling key industry players to discuss solutions.
Providers, meanwhile, are doing battle against medical errors on the front lines, sometimes using such technologies as computer-based patient record systems and electronic physician order entry to track and prevent errors. Newer to the field are innovations such as computer simulation and military-based teamwork training.
Whatever methods they're using, providers aren't waiting for policy changes.
"People at the front end (of medicine) are being proactive and determining solutions. That's the kind of action that will lead to the policy changes we need," says Martin Hatlie, who recently launched the Partnership for Patient Safety (P4PS), a for-profit consulting network of individuals and organizations developing information, products and services to improve patient safety.
P4PS will co-sponsor a conference June 28-30 in Dallas that will focus on what purchasing coalitions, providers and educators can do. "The private sector has a huge job in meeting public expectations to improve safety," Hatlie says.
The organizations involved include the Carlson School of Management, the Harvard Risk Management Foundation, the Joint Commission on Accreditation of Healthcare Organizations, the Medical Group Management Association, the National Business Coalition on Health, and purchasing alliances Premier and VHA.
One goal of the conference, Hatlie says, "is to create a community of people who are working across disciplinary lines to tackle this issue. You can't make a change in the pharmacy or purchasing department without addressing how it affects the entire landscape."
Joanne Turnbull, who took over as executive director of the AMA's National Patient Safety Foundation in March, says the healthcare industry should stop pointing fingers at individual caregivers and work to improve the system. "The foundation focuses on system change, not individual blame," she says. "We believe that making mistakes is part of the human condition. The solutions are in the system."
In an effort to find those solutions, the foundation also will hold a conference in Chicago May 8-9 that will bring together representatives from the legal, consumer, research and provider communities, as well as regulatory and government officials, to come up with a plan to improve patient safety. Among the organizations involved are HHS' Agency for Healthcare Research and Quality, JCAHO, Kaiser Permanente and the U.S. Department of Veterans Affairs.
Meanwhile, hospitals are finding that even small changes, such as training residents on simulators, can make a difference. "There's no excuse for practicing and learning on patients when this technology is available now," says Gregory Merril, founder and chairman of HT Medical Systems, which developed the PreOp Endoscopy Simulator, another tool employed at Children's Hospital Oakland.
The Gaithersburg, Md.-based company has been developing simulation products over the past 10 years with financial assistance from government agencies such as HCFA and the U.S. Department of Defense as well as device and pharmaceutical companies. Its other products include the CathSim Intravenous Training System, which teaches basic needle-stick procedures, and the PreOp Endovascular Simulator, which trains physicians to perform interventional cardiology or radiology procedures, such as angioplasty. A simulation system costs about $30,000 and can be used for multiple procedures by adding software.
Several hundred nursing schools and residency programs at teaching hospitals use HT Medical's products. At Children's Hospital Oakland, 30 to 40 residents have trained with the PreOp Endoscopy Simulator since last August, Rowe says. The hospital plans to examine the cost-effectiveness of the system over the next few years, he says. Rowe thinks the simulator will prove less expensive and more successful than training residents in the operating room. For one thing, it could cut down on the $9-per-minute labor costs of teaching a resident in the operating room.
Other technologies, such as computer-based patient records and electronic physician order entry, have enjoyed well-documented successes at facilities such as LDS Hospital in Salt Lake City and Brigham and Women's Hospital in Boston.
There's more to reducing medical errors than installing a new computer system, however.
"We're suggesting that we change our fundamental model--how we think about errors," says Brent James, M.D., an author of the IOM report. "While a few are due to negligence, the vast majority are due to system errors under which caring, concerned, well-trained people make mistakes."
James is vice president for medical research and executive director of the Institute for Health Care Delivery Research at Intermountain Health Care. The Salt Lake City-based integrated delivery system includes LDS and 22 other hospitals. IHC is renowned for its use of clinical process management to improve quality of care. The system uses computers to track medical errors and then devises and tests hypotheses for improving care, implementing those that work best. Through clinical process management, the system has eliminated more than two-thirds of its adverse drug events.
Facilities that design their own computer systems, such as LDS and Brigham and Women's, have done the best jobs in reducing errors with such technology, says Peter Kilbridge, M.D., practice director with First Consulting Group's emerging practices group in Boston.
"The in-house programs were designed by physicians for physicians' use," Kilbridge says. "There's a void in the commercial marketplace for products that appropriately address physician order entry requirements." To be of real value to physicians, he says, an order entry system should check for such potential problems as drug interactions and patient allergies, and most commercial products do little or no such monitoring.
Another downside to computer-based technologies is cost. At a medium-sized hospital with existing information technology, an order entry system might cost $1 million to install, and a computer-based patient record system could cost $10 million, Kilbridge says.
The current frenzy over patient safety might cause hospital chief financial officers to loosen their purse strings. "New information systems for a large hospital are a hard sell," Kilbridge says. "The things that will drive that sell include the furor over patient safety. Hospitals will need to more broadly assess physician order entry, or at least pieces of the process, to reduce medical errors. Every hospital should be thinking seriously about reviewing its medical error situation and all the processes involved."
While technology is an important link to improving patient safety, it can't fix everything in a dynamic industry like healthcare, says P4PS' Hatlie. "Better communication and teamwork training among the people in healthcare is very important," he says. "In military models, they teach people to migrate into nonhierarchical teams during a crisis. A person might not have the rank but has the knowledge. The lower-ranking people during a crisis need to be empowered to make decisions."
That's the thinking behind MedTeams Teamwork System, which teaches emergency department personnel to communicate better and work together more efficiently.
Dynamics Research Corp., an Andover, Mass.-based engineering services and consulting company that works extensively with the military, devised MedTeams.
The government-funded project was launched in 1996 as an experiment at 12 military and civilian hospitals across the country.
Participating hospitals send a nurse and physician from their EDs to undergo a week of training at DRC. The pair then returns to the hospital to train the rest of the staff and set up the program in which teams are given responsibility for care of assigned patients.
"A (team member) is given the tools to politely, respectfully, challenge the physician because it's not just one person that's responsible for the patient's welfare," says Robert Simon, chief scientist for the crew performance group at DRC and project manager of MedTeams. "It's really empowering to the whole team."
He stresses that this should not be perceived as questioning the physician's authority but rather as acting in the patient's best interest.
The results of the 12-hospital MedTeams experiment are currently under peer review, and no hard data will be available until this summer. However, Simon says preliminary data show improvements in patient safety and satisfaction and reductions in lengths of stay. MedTeams estimates EDs that implement the program will save $4 to $10 per patient visit through reduced litigation costs and improved efficiency.
So far, seven hospitals are on board to adopt a commercial version of the training system. It costs $65,000 for the first year and $20,000 annually thereafter and can be implemented in three to four months, depending on the size of the hospital. Costs include ongoing consulting, installation of a continuous quality improvement system and other services. No technological purchases are necessary.
"This program gets to the heart of the culture," Simon says. "It's not, 'OK, we'll put bar codes on prescriptions and that will prevent us from making errors.' It really changes the nature of relationships in the emergency department."