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EDITORIAL
Year : 2007  |  Volume : 51  |  Issue : 5  |  Page : 363 Table of Contents     

What's New in Patient Safety and How It Will Affect Your Practice


Editor, IJA, India

Date of Web Publication20-Mar-2010

Correspondence Address:
Pramila Bajaj
Editor, IJA
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Bajaj P. What's New in Patient Safety and How It Will Affect Your Practice. Indian J Anaesth 2007;51:363

How to cite this URL:
Bajaj P. What's New in Patient Safety and How It Will Affect Your Practice. Indian J Anaesth [serial online] 2007 [cited 2020 Sep 27];51:363. Available from: http://www.ijaweb.org/text.asp?2007/51/5/363/61165

"The value of history lies in the fact that we learn by it from the mistakes of others, as opposed to learning from our own which is a slow process"

While millions receive medical care every day, high profile cases have brought medical errors and patient safety to the public's attention. There is a clear need to improve the quality of care in the medical system that permits an alarmingly high rate of medical errors that harm tens of thousands of patients and drives up cost. Modern medical care is complex, expensive, and at times dangerous. Acute care environments, such as operating rooms and intensive care units are characterized as complex, tightly coupled systems intrinsically prone to accidents. Highly coupled systems are made up of a series of Microsystems-small teams of providers and staff working together to provide care for a defined population of patients. To understand the functioning of these health care microsystems, and to improve perioperative patient safety, it is necessary to study the components that make up the system - humans, technologies and their complex interactions. In health care, the premium placed on practitioner autonomy, the drive for productivity, and the economics of the system may lead to severe safety constraints and adverse medical events. Several key building blocks must be addressed before other solutions to the problem of unsafe medical care can be considered. Among these building blocks are the need to address the impact of production pressure, optimal use of technology and information, design of the perioperative setting, and the need for standardization of practices.


   Anaesthesiology as a leader in health care Top


The field of anaesthesiology is a celebrated example in health care, in which an organized and continuous effort over a period of 20 yr has led to major improvement in patient safety [1] . The safety of anaesthetic procedures has improved several fold in the last 40 years (from 2 deaths/10,000 to 1 death/300,000 patients) [2] . Many feel that the overall approach in the field of anaesthesiology has led to a 100-fold safer profile than the rest of health care. We have also been lauded for our leadership in setting quality standards ahead of the pay for performance drive which today includes Medicare, employer groups, and several sponsored health care plans [3] . The tools routinely deployed to make anaesthesia safer include team training [4] , simulation [5] , incident reporting [6] , and safety systems training [7] . How­ever, it is also clear from other studies that we have still much work to do. It has been suggested that for patients less than healthy (with ASA clinical status more than an ASA score of 3), we have made little progress in improving safety over the last several decades [8] . Cooper and Gaba challenge this assertion saying that "anaesthesia for healthy patients is safer than it once was (but further progress may be possible); the rate of anaesthesia-related mortality for all surgical patients is still higher than desired; and, safety levels can plateau or even diminish over time without constant effort at improvement" [9] . The later admonition needs to be taken to heart to ensure the safety of our patients.


   Looking toward the future Top


The health care system has only recently begun to approach patient safety in a more systematic way. There is a clear need to improve the quality of care in the medical system that permits an alarmingly high annual rate of medical errors that harm tens of thousands of patients and drives up cost. Anesthesiologists, the Anesthesia Patient Safety Foundation, and the ASA were among the pioneers to adopt the new framework and systems thinking towards patient care. Much work still needs to be done to change the mindset of the perioperative setting towards a system based patient safety approach. The usual approach within medicine has been to stress the responsibility of the individual, and to encourage the belief that the way to eliminate adverse events is to get individual clinicians to perfect their practices. This simplistic approach not only fails to address the important and complex systematic flaws that contribute to the genesis of adverse events, but also perpetuates a myth of infallibility that is a disservice to both clinicians and their patients. The focus on the actions of individuals as the sole cause of adverse events inevitably results in continued system failures and the resultant injuries and deaths of patients. The efforts of the JCAHO, National Quality Forum, CMS, ACGME, and others to align external financial, regulatory and educational incentives are beginning to have an impact on providers to embrace the safety and quality themes described above. Strategies to consider in making anesthesia care even safer might include adoption of safety science principles, setting up robust reporting systems, applying critical event analysis tools such as Root Cause Analysis and Failure Mode and Effects Analysis, wide adoption of simulation and team training, deploying robust handoff protocols and patient identification checklists, and adherence to practice parameters. A growing interest supports a widespread implementation of elec­tronic medical records to reduce medical harm while reducing cost. There is a pressing need to expand and raise the regularly approval bar of medical devices by ensuring that all devices have human factors input, and extensive usability data before devices are approved for market. The cultural and process changes require profound alterations in management thinking, staff empowerment, and improved communications skills. Attributing errors to system fail­ures does not absolve physicians and nurses of their duty to care. In fact, acknowledging system failures adds to that duty the responsibility to admit errors, investigate them, and participate in redesign of a safer system.

 
   References Top

1.Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist direction and patient outcomes. Anesthesiology 2000;93:152-63.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Beckman U, West L, Groombridge G, et al. The Australian incident monitoring study in intensive care: AIMS-ICU. The development and evaluation of a voluntry anonymous incident reporting system. Anesth Intensive Care 1996;24:315-26.  Back to cited text no. 2      
3.Paying doctors for better care[Editorial]. New York Times, December 26, 2006.  Back to cited text no. 3      
4.Baker D, Gustafson S, Beaubien J, et al. Medical teamwork and patient safety: the evidence-based relation.2005. AHRQ Publication No.05-0053.  Back to cited text no. 4      
5.Gaba DM, Howard SK, Fish KJ, et al. Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience. Simulat Gaming 2001; 32:175-93.  Back to cited text no. 5      
6.Morray JP, Geiduschek JM, Ramamoorthy C. Anesthesia related cardiac arrest in children: initial findings of the pediatric perioperative cardiac arrest registry (POCA). Anesthesiology 2000;93:6-14.  Back to cited text no. 6      
7.Reason J. Managing the risks of organizational accidents. Aldershot, UK: Ashgate, 1997.  Back to cited text no. 7      
8.Lagasse RS. Anesthesia safety: model or myth? Anesthesiology 2002;97:1609-17.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Cooper J, Gaba D. No myth: anesthesia is a model for addressing patient safety. Anesthesiology 2002;97:1335-7.  Back to cited text no. 9      




 

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