Patient Safety Forum Sheds Light on Lessons for Healthcare from Other Industries
Posted September 15, 2013
What can healthcare learn from other industries, particularly when it comes to patient safety? A lot, apparently. That was the message delivered by representatives from the healthcare, government, consumer research, and the business communities who came together at the Inaugural Johns Hopkins Patient Safety Forum, which took place Sept. 23-25 in Baltimore, MD.
Captain Chesley Sullenberger
Captain Chesley “Sully” Sullenberger, the pilot who landed Flight 1549 on the Hudson River in 2009, detailed his experience in the aviation industry to show how it has learned from the past to keep passengers and crew safe now.
Sullenberger provocatively noted during his talk that if planes were operated in the same way as intensive care units and operating rooms, with monitors and machines that cannot communicate, the aviation industry wouldn't be able to perform the way it does, and passenger safety would be compromised.
In aviation, the industry as a whole learns from mistakes, Sullenberger said. "Aviation wasn't nearly as safe 40 years ago when I started as it is now," he said. Pilots operated with autonomy, and their crews often were afraid to report unsafe practices. But with increasing numbers of accidents came the realization that something needed to change.
In the 1980s, Sullenberger helped design a course to increase human performance that focused on leadership, team building, and error tracking. Pilots and their crews began working more as teams."We made it not about who's right, but what's right," he said. In addition, those in aviation can recite details about crashes that have occurred over the last half century. They look to the past to make sure the routine aspects of flying go smoothly, but they are also striving to do better and recognize potential risks. Just because an accident hasn't happened, doesn't mean there are not still risks. Risk mitigation is essential—this lesson needs to be brought to the C-Suite in healthcare, he said.
Peter Pronovost, MD, PhD, a critical care doctor at Johns Hopkins Hospital and director of the Armstrong Institute for Patient Safety and Quality, also emphasized the need for all healthcare workers to work as a team. It shouldn't be nurse versus nurse, clinician versus clinician, or clinician versus nurse—this situation leads to a breakdown in communication and harms patient care.
Pronovost named other ways to help improve patient care, including the need to stop playing the blame game. "It's the regulators fault; it's the vendor's fault"; there is a lot of judgment rather than understanding. The players need to stop blaming and work together. And that working together needs to extend to outside the healthcare facility. There needs to be "communitarian regulation," he said. He highlighted this year's creation of the CommonWell Health Alliance, through which Cerner, Allscripts, athenahealth, Greenway Medical Technologies, and McKesson, along with its RelayHealth connectivity business, unveiled a not-for-profit organization to support universal access to healthcare data. Computer Programs and Systems, Inc. (CPSI) and Sunquest Information Systems joined the group in July.
In the meantime, clinicians are getting burned out. Healthcare information technology is seen as a savior—as a vast improvement over paper. But much still needs to be done.
Pronovost also sees the theme of heroism as being a problem for facilities. Clinicians and nurses coming in just in time to save patients. "That might sound noble to you. But it isn't nobility; it's about safe design," he emphasized.