Not so long ago, at a Department of Veterans Affairs hospital not so far away, VA health professionals were beginning to zap medical errors with their high-tech weapons.
It's not "Star Wars," but this battle for healthcare quality does resemble a scene from the sci-fi trilogy: Nurses marching through wards with red laser scanning guns, while physicians in white coats call up detailed digital images from a host of computer stations. In this case, the enemy doesn't wear a black helmet. But, like Luke Skywalker, the hero has flown spaceships.
Two years ago, the VA hired a former space shuttle astronaut, James Bagian, M.D., 48, to lead legions of VA hospital employees in the fight against medical errors.
Though the VA has the technology to reduce errors, Bagian's real mission is to win converts to its new patient-safety program, which features mandatory and voluntary reporting systems for errors and close calls.
Bagian, director of the VA's National Center for Patient Safety in Ann Arbor, Mich., is spending the better part of May and June on the road to personally roll out the program.
"This job is every bit as challenging as flying the space shuttle, and even more rewarding," Bagian says. "I feel privileged to have the opportunity to do things that people haven't done before."
The VA began boldly going where no health system has gone before far in advance of the release of the influential Institute of Medicine report on medical errors last year. But the report, which said that as many as 98,000 people die each year because of medical errors in hospitals, gave the VA the chance to shine.
"All of the IOM's recommendations that were applicable to the VA were either already in place or in process when the IOM report came out," Bagian says. "We interpreted the IOM report as a validation of our commitment to improving patient safety in our healthcare system."
A tarnished image. Just a few years ago, VA hospitals were fighting to shake off the bad reputation they received in the wake of some egregious--and preventable--errors. Media reports blasted the quality at VA hospitals, and Congress held hearings to find out what was going on.
Bagian says that image was undeserved and attributes the recent favorable publicity to Kenneth Kizer, M.D., who up until July 1999 was the VA's deputy undersecretary for health.
Kizer, 49, now president and chief executive officer of the National Quality Forum in Washington, said 1997 seemed like the perfect time for the VA to not only deal with the negative publicity but to make headlines as a leader in patient safety.
"These (errors) were going on everywhere, but the big difference was that we were a public entity, so we were being open about it," Kizer says. "I thought, `If we're going to be criticized, let's do the right thing and be very public about it.' "
The bold experiment in error reporting began six months ago, when Jeffrey Lee, chief quality management officer of Veterans Integrated Service Network 8--which includes 21 facilities in Florida, Puerto Rico and the U.S. Virgin Islands--personally volunteered the network of hospitals to be the guinea pig for the patient-safety system.
"It was an exciting opportunity to help develop and mold and create the future of patient safety," Lee says.
A simple formula. The reporting system sounds simple. Hospital employees determine whether an error, called an adverse event, or a "near miss" has occurred. If so, it's reported, and the clock starts ticking on the root-cause analysis--the process used to determine what led up to the event, not who made the mistake.
The hospital director chooses a team of three to five people, depending on the event, to conduct the analysis. The team never includes anyone who was directly involved in the event, but the team does, of course, interview those key players to find out what happened, Lee says.
"They keep asking, `Why? Why? Why?' until they get to the heart of the problem," Lee says. "They're asked to do a flow chart diagramming the processes as they understand them. Then they are asked to identify the root causes (of the error) and the contributing factors."
Usually within a few days, the team compiles all this information into a report and shows it to the original reporter of the event. "Is this what happened?" the team asks. "Are we on the right track?"
"This shows a tremendous amount of respect to the reporter, but it also gives the sense that the team is being reasonable," Lee says.
Management's commitment required. One of the most important resources involved in a root-cause analysis is time. Management has to tell the team members: This is your assignment for the next few days, so put aside your other responsibilities and get this done.
Successful error-reporting and analysis also requires comprehensive training and the undying support of management, Lee says.
"You have to have that commitment by leadership that we are, in fact, going to make a difference," Lee says. "The National Center for Patient Safety does that very well."
It's quite a task, even for Bagian, who was one of the lead investigators of the 1986 Challenger space shuttle disaster.
The VA spent 1997 doing some ground work to figure out where they were and where they wanted to be. In 1998, the VA established the patient-safety center as a home for the system's error-prevention and quality-improvement initiatives. The momentum for a safety program was gathering steam. All roads were leading to error-reporting, and VA health professionals were afraid to think about it because they didn't want to get reprimanded or fired.
"We had to win them over," Bagian says of the hundreds of VA employees who are using the system. "You have to invite people to play. You can order people to do things, but if they don't believe in it, they won't want to do it."
Bagian is not happy that his work takes him away from his wife and four children, but he is discernibly proud of what he and the VA staff have accomplished. By August, all 173 hospitals in the VA system will have the patient-safety program in place. As of mid-May, six of the VA's 22 hospital networks had the system up and running.
Attention from the private sector. The private sector--including the American Hospital Association and the Joint Commission on Accreditation of Healthcare Organizations--is paying close attention to what the VA is doing.
Since 1997, the Joint Commission has required hospitals to track serious medical errors, which it calls sentinel events, and to perform a root-cause analysis similar to what the VA hospitals do. But there are a few major differences.
For example, the Joint Commission asks hospitals to voluntarily self-report medical errors to the commission in exchange for leniency from accreditation surveyors. If hospitals don't self-report and the commission finds out about the event, they will be placed on accreditation watch, which is a probationary period, while the commission investigates.
The VA requires its hospitals to report medical errors and close calls. It also has a voluntary component to its reporting system so hospital personnel and patients can report unsafe conditions to an external entity.
The VA's policy also requires more-immediate action on medical errors, which must be initially reported within 24 hours of their occurrence. A root-cause analysis is usually completed within a few days.
The Joint Commission gives hospitals five days to self-report and 45 days to complete a root-cause analysis.
Russell Massaro, M.D., executive vice president of accreditation operations at the Joint Commission, says the VA's system dovetails nicely with the commission's sentinel-event policy--which is a good thing, since VA hospitals are subject to Joint Commission accreditation just like private hospitals.
"It's an excellent (error-reporting) system," Massaro says. "We (on the JCAHO staff) were all very impressed with its sophistication and comprehensiveness."
Important tools. It helps that the VA has two tools in place that make it easy to provide high-quality care: the electronic patient record and computerized pharmacy functions.
"(The e-record) is an absolute must for where we need to go, not just for medical-error prevention, but for collecting data on quality," Kizer says. "The government needs to take a man-on-the-moon approach to this and say, by a certain year, we will do this. It's a public good that needs to happen."
Ross Fletcher, M.D., chief of staff at 278-bed VA Medical Center in Washington, gushes about e-records. Fletcher, a cardiologist, helped develop aspects of the VA's e-record and has served on VA advisory panels on computer development.
In almost every area of the hospital, paper charts are used solely as a backup. E-records include every conceivable type of data a physician or nurse would need--a history of visits, a list of medications, notes from physicians, vital signs, digital X-rays and endoscopies.
At this medical center, nurses and physicians can access the e-records from 1,500 computer terminals, Fletcher says.
"(Paper) records were 20 inches thick, and now they are maybe two inches, if not two-tenths of an inch," says Fletcher, who is also a professor at Georgetown University's medical school. "Now we work off a simple, standard PC. We can look through a very robust database very fast, and make correlations that we couldn't make before."
The e-record system tells users if there is more than one patient with the same last name and prompts them to check which patient they really want. It lists clinical reminders, such as a blood pressure check or an eye exam for a patient. It also allows two physicians, in two different locations, to view the same record simultaneously and discuss the best course of treatment.
Of course, physicians weren't always so gung-ho about the electronic-record system.
"One of the advantages of being in the VA is that the software is used in 173 hospitals by thousands of physicians who all complain," Fletcher says. "So testing for the software was very quick and very responsive."
Fletcher says the e-record helps prevent errors or misdiagnoses in many ways, mainly by providing more and better information to physicians. In addition to the patient-specific data it contains, the system allows physicians to use Internet links to dozens of medical journals.
"I use the Internet all the time," Fletcher says. "One of the safest things that can happen is having a full breadth of medical knowledge. That makes it hard to make a mistake."
Fletcher also can use the e-record system to glean data on patient outcomes by physician and determine who is giving their patients the best care.
"The doctor can see how he or she is doing compared with everyone else," says Fletcher, who e-mails the findings to the hospital's medical staff. "It's peer pressure, and that's what drives us best and keeps us getting better and better."
Pharmaceuticals online. The VA hospital in Washington, like others in the VA system, also has gone 21st century with computerized drug ordering and dispensing. That eliminates the need for handwritten prescriptions, which many healthcare professionals find illegible.
"It used to take 90 minutes or more to get orders in (to the pharmacy)," says Ron Schneider, a pharmacist at the VA medical center in Washington. "Now we have a real-time system. The doctor types it in, and it's printed out right here in the pharmacy."
Physicians like it, too.
"There's no guessing," Fletcher says of the drug-ordering system. "I don't have to remember what tablet sizes the drugs come in, and it's hard to order a nonstandard dosage."
All drugs bear a bar code that can be read with a scanning gun. If the drug's manufacturer doesn't place a bar code on the product, the hospital's pharmacy does.
Nurses make their "med passes," or medication distribution rounds, with a laptop computer, a touchscreen wand and a cordless scanning gun.
Armed with these tools, the nurse scans the patient's bar-coded wristband. On the computer screen up pops the patient's identification and medications that should be given.
Next, the nurse scans the barcoded medication. If it's the correct drug, the correct dose, the correct time to administer it and the correct patient, the nurse distributes the medication. If not, an error message on the computer screen tells the nurse not to administer the drug.
The total cost for the bar-coding system? A mere $360,000 for the Washington VA hospital.
"As one (hospital) CEO noted, that's not even a lawsuit," Schneider quips.
What the healthcare industry really wants to know is: How many errors has the VA prevented with these systems? By how much has the number of errors fallen since these systems were put into place?
But in the same way that healthcare professionals want to move away from finger-pointing when identifying errors, VA officials want to steer away from describing their successes in numbers and bar charts.
"Our quality-management people want to know why our medication-error reporting has dropped. Well, it's because you can't commit errors with this (bar-coding) system," Schneider says, rolling his eyes. "We don't know how many errors we've prevented, but we've prevented them. A lot of them."
While technology plays an important role in error-reduction, it can go only so far, Kizer says.
"If you are going to do something meaningful, there has to be inspired leadership, an infrastructure, dedicated resources and (computer) systems to support it," Kizer says. "Patient safety has to have a home. What we tried to create with the National Center for Patient Safety can be adjusted to health systems of any size."
It's also good to have goals. In its report, the IOM challenges providers to reduce errors by 50% during the next five years. Bagian laughs at the idea.
"I want to eliminate all errors, not just 50%," Bagian says. "That way, you don't have to count them. But especially if there's nothing to report, we need to ask, `What can we do better?'
"The only way to reduce risk is to be mindful of it every day. In aviation, after every flight, the crew sits down and goes over what happened. In medicine, it's not done. My astronaut friends look at me and say, `You have to explain that to people?' "