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CLINICIAN to CLINICIAN

Daily miracles despite a rocky foundation

Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective and potentially dangerous. -- Sir Cyril Chandler

Each day at Allina Hospitals & Clinics, countless miracles benefit our patients and their families:

• Very preterm infants are born with the best survival rates in the nation within Allina Pregnancy Care.
• A resident of New Ulm experiences acute myocardial infarction (AMI) and 82 minutes later receives an angioplasty at Abbott Northwestern Hospital in Minneapolis.
• Magneto encephalography at the Nasseff Neuroscience Center of United Hospital exactly pinpoints a patient's seizure locus.
• Allina Grief Resources help families navigate their way through the loss of a loved one.

With hundreds of instances of great care happening each day, isn't patient safety a given fundamental? Regrettably, the answer is, "Not always."

Medical errors

In the United States, medical errors are the eighth leading cause of death – surpassing deaths from motor vehicle accidents, breast cancer and AIDS.

As physicians, we have been socialized to be the captain of the ship and responsible for our patient's outcomes. But we need to understand that the vast majority of errors do not represent the shortcomings of individuals. Rather, it is a collection of individuals, the communication between them, and the systems that support them that needs to work together to eliminate errors.

As Harvey Fineberg, MD, president of the Institute of Medicine said, "Instead of thinking how to train clinicians who are capable of doing the right thing flawlessly, we ought to think about designing systems that are incapable of doing the wrong thing."

Emerging models for health care are based on those successful in other complex fields like aviation. Aviation has transformed its safety culture by paying attention to crew coordination and communication, sharing stories of near misses and adverse events, creating checklists and adhering to consistent protocols. Anesthesiologists, among other segments of health care providers, have used these same techniques to dramatically reduce risks to patients.

Improving the safety of patient care

So what are we doing at Allina to continually improve the safety of care to our patients? We have several initiatives occurring within our care sites to strengthen the safety foundation required for quality care.

• Our strategic goals include increasing the reliability of care, defined as failure-free care over time from the patient's perspective. We are focusing on the best care for acute myocardial infarction (AMI), pneumonia, congestive heart failure, diabetes, depression and preventative screening. We are also focusing on teamwork and communication in high-risk areas such as obstetrics and surgery.
• We continue to refine Excellian, our electronic medical record system, so that it enables physicians and other caregivers to more easily give the best and safest care possible.
• Hourly nurse rounding piloted in three hospitals has been shown to decrease harmful events while increasing staff and patient satisfaction. This best practice of hourly rounding will be spread across the organization.
• Physician leaders are participating in educational opportunities to learn how best to lead the organization in improving safety.
• Allina is also participating in the Safest in America collaborative. This unprecedented community collaboration of all the hospital systems in the metropolitan area and Mayo Health System will involve physicians, nurses and other care providers in defining best safety practices and behaviors.

By working together and becoming a place where errors are discussed and learned from, we can build a solid foundation for exceptional care. In that vein, I encourage each and every one of us to come forward with any information that can improve the quality and underlying safety of the care we provide.

I want to hear from you.

I thank each of you who responded to my previous article on patient-centeredness. I welcome further ideas as to how we can continue to improve the care we provide.

E-mail me, call me at 612-262-0605, or stop me when I'm visiting your medical center (I'm trying to get out to an Allina facility every week). I'd love to hear from you.  

Related Links

Patient safety

Safest in America

First published: 05/21/2007
Last updated: 05/21/2007

Reviewed by: Penny Ann Wheeler, MD, chief clinical officer, Allina Hospitals & Clinics