4 minute read
Chew On This
BY KEITH CHEW
Medical errors are now the third leading cause of death in the United States. If this was an Olympic event, that would be a bronze medal.
This is not a statistic the medical community is proud of, nor is it one that can be ignored. Medical error reduction and prevention is a challenge being addressed across all aspects of health care.
To address the issue, it’s essential to understand the problem and what constitutes a medical error; a few of the most common errors include: • Medication errors • Anesthesia errors • Hospital-acquired infections • Missed or delayed diagnosis • Avoidable delay in treatment • Inadequate follow-up after treatment • Inadequate monitoring after a procedure • Failure to act on test results
My final column in this series on cross-industry learnings has us focusing on the energy industry – specifically the nuclear energy industry. By carefully studying these errors, as well as how similar industries manage mistakes, we can learn to prevent them in the future.
Like health care, nuclear energy companies need to be highly reliable organizations. Atomic reactors are some of the earth’s most sophisticated and complex energy systems. However, any complex system, no matter how well designed and engineered, cannot be deemed failure-proof. Given the high human, environmental and financial cost of a radioactive leak, these companies go to great lengths to bring errors theoretically to zero. Here are some approaches from the nuclear energy sector that the health care industry can learn from and apply to address medical errors.
CATCH THE ISSUE BEFORE IT BECOMES A MELTDOWN
Nuclear infrastructure safety is all about defense-in-depth, a strategy that leverages multiple levels of security measures to protect or prevent errors. This approach works to limit the chance that any small or even large issue results in a dangerous nuclear meltdown. At a nuclear power plant, depth is the physical distance between radioactive materials and civilians as well as the depth of the contingency/backup plan. Nuclear meltdowns are avoided by the rods that mitigate the radioactive power of the reactor’s uranium fuel, the massive steel reactor vessels and cooling systems that hold and cool the rods, and the several feet of steel-reinforced concrete that houses the reactor vessels. If standard equipment malfunctions, multiple redundant safety equipment options are in place. Within health care, there are not nearly as many double checks or backup security options applied in clinical practice for patient safety.
A SECOND SET OF EYES APPROACH
While safeguards are critical for limiting
incidents, errors do occur and their root cause must be understood to prevent those errors in the future. As one nuclear energy researcher stated, “the problem with new reactors and accidents is twofold: scenarios arise that are impossible to plan for in simulations, and humans make mistakes.” To address this, the nuclear power industry has gone to great lengths to understand these human mistakes and learn from them.
For example, multiple stakeholders review each reactor plan to ensure safety. First, the U.S. Nuclear Regulatory Commission (NRC) oversees plant safety and security for commercial U.S. nuclear reactors. One oversight initiative is the Resident Inspectors Program, where two individuals are stationed at each plant, daily auditing people, processes and technology to prevent errors. Furthermore, the nuclear power industry conducts peer reviews of plant operations through the Institute of Nuclear Power Operations, the International Atomic Energy Agency, and the World Association of Nuclear Operators to identify and mitigate possible errors whenever feasible.
Health care has the radiology peer review process in which providers randomly double-check their work to ensure diagnostic medical errors are identified, utilized as learning experiences and are ultimately resolved. Unfortunately, only 3 to 5% of the total imaging volume of a hospital receives this safety net peer review, leaving over 90% of all radiology images with only a single review.
Another factor in the medical error cycle is that hospitals haven’t fully bought into a streamlined incident reporting process or a blame-free just culture. At a result, 40% of U.S. hospitals are not leveraging the numerous benefits of patient safety organizations (PSOs). PSOs allow for the safe identification of errors that lead to quality and safety issues and enable the next step of developing interventions to prevent and mediate errors in a true peer learning atmosphere.
Pioneering health care leaders can learn from the nuclear energy industry and work within their hospitals to implement redundant checks across the entire patient journey. In addition, the use of technology, such as AI for a second read across all imaging scans, and adopting a true peer learning philosophy will be critical in positively impacting medical error.
Health systems can leverage these cross-industry learnings by asking a few questions: • What is your health system’s defense-in-depth strategy for limiting medical errors? • Does your health system have a radiology second read program in place that assesses the vast majority of images or just the routine 3 to 5% that fall within the credentialing required peer review process?
Is your hospital a member of multiple PSOs with each focusing on a different aspect of quality improvement? If yes, how is your hospital using those programs to learn and change behavior moving forward? If no, is joining multiple PSOs something your hospital should consider and research? Join us next month as we do a series re-cap! •
Keith E. Chew, MHA, CMPE, FRBMA, is a principal with Consulting with Integrity.
