Q&A: 'We have a long way to go yet on patient safety'

As president and CEO of the National Patient Safety Foundation, Dr. Tejal Gandhi tackles issues such as diagnostic errors and unintended harm from electronic health records. Modern Healthcare quality and safety reporter Sabriya Rice recently spoke with Gandhi about these and other concerns of the patient safety movement. The following is an edited transcript.

Modern Healthcare: What do you see as the area of most concern to patient safety advocates today?

Dr. Tejal Gandhi: I worry about complacency. We have been working on patient safety for over 15 years, and often there are new priorities that come around like population health or cost reduction. We have a long way to go yet on patient safety.

MH: Is your patient safety work shifting from inpatient to outpatient settings?

Gandhi: Expanding our work to settings outside of hospitals is critically important. Most care is given outside of hospitals. It makes sense that we started in hospitals where there's high acuity and lots of risk. There are significant safety issues that can happen in primary-care settings, in nursing homes and in home care.

What it's going to take is a better awareness of what those issues are and more leadership focus on these settings.

The third thing we need to do is develop some infrastructure, because ambulatory settings often don't have the quality and safety infrastructures of hospitals.

MH: How are electronic health records in hospital settings having an impact on patient safety?

Gandhi: The potential for enhancing quality and safety through those records is large. The challenge, though, is that often the technologies are not well-integrated into workflows so are maybe not achieving those quality and safety benefits.

They are creating some new unintended harms as well. We really need to figure out how to optimize these technologies to make sure that they're really improving quality and safety, while not creating new unintended consequences.

MH: How do you make that happen?

Gandhi: One way to improve coordination is with better interoperability and more ability to communicate information across the care continuum. A lot of organizations have been doing innovative things to help make these transitions of care across various settings more effective, such as having more person-to-person communications as opposed to just relying on paperwork; making sure patients have follow-up appointments and follow-up phone calls when they're in those transition moments; even having case managers to follow patients along all those stops on the continuum to make sure care is coordinated.

MH: Do you think that patients are involved enough now?

Gandhi: We can do a lot more in terms of communicating with patients about care plans and about risks and benefits of various treatment options. We've done a lot of work about communicating better when errors happen and when harm happens, and being much more upfront and truthful about those things. But also we can do a lot better with engaging patients in improvement work (by) asking patients about issues that are coming up and then involving them in the solutions. We often create the improvements without the patient voice at the table.

MH: You had a chance to review the National Academies of Sciences, Engineering and Medicine's recent report focused on diagnostic errors. How big of a challenge is that issue?

Gandhi: It's a newer area that we're really trying to focus on. We need a culture change where clinicians are much more comfortable talking about diagnostic errors and getting feedback.

I think about them in terms of core systems that need to get better, like how we manage test results and how we manage referrals. But then also there's a really challenging area around cognitive error. Errors will happen, human beings will make cognitive errors. But how do you build a system that will, hopefully, catch those before too much time goes by and a diagnosis gets very delayed? There will be a lot of work over the next decade trying to understand the causes of cognitive error and what interventions will hopefully mitigate some of those errors.

MH: How do you identify your own biases as a clinician?

Gandhi: A lot of those biases help us make really good rapid diagnoses. So they work for us a lot of the time. But then 10% of the time they might lead you astray. There's a lot of discussion about how do we do better education and training for clinicians so they are more self-aware of their cognitive biases, potentially through things like simulation, for example.

That kind of training and education is necessary but not sufficient because no matter what, in a busy, harried day where there are interruptions and distractions, human beings will make mistakes. So we have to build that supportive system around education and training so that if that error still happens, we can catch it early.

MH: You recently formed a work group on the copy-and-paste problem. What is that and how does it cause patient safety issues?

Gandhi: One of the unintended consequences of health information technology is copy and paste. Before, we would handwrite our notes. Often they were unintelligible and hard to find. The idea was the computer was going to make notes legible. In a lot of ways, it has improved timeliness and the ability to find notes.

From an efficiency standpoint, copying and pasting information can help you write your notes faster. But often people are doing too much copying and pasting.

Vendors, providers, insurers, safety experts, and researchers are trying to tackle some of these new unintended consequences of health information technology. Our work group on copy and paste had all of those voices at the table and we developed a tool kit that would give recommendations to vendors about how they might design their systems to make it easier to know what's been copied and pasted.

We also made recommendations for health systems about how they might train and educate their clinicians about the use of copy and paste. Are they using it effectively versus ineffectively? Every hospital around the country is individually trying to solve this issue, and I think there's a real value of saying at the national level here are some best practices so every hospital doesn't have to try to tackle it independently.