During National Patient Safety Awareness Week, I am reminded of a bumper sticker I once read on a passing truck; “Our Goal is Zero Accidents”.
Really? On time delivery, no damaged goods, customer satisfaction, SLAs, and all you could come up with was zero accidents? Setting the bar a little low, wouldn’t you say?
Upon reflection, perhaps the most notable distinction about our healthcare system today is that it is recognized for providing less than optimal outcomes at a very high cost. Last time I reviewed the Partnership for Patients Initiative the goal was to deliver affordable access, safety and quality care. Although there have been significant strides in automation (which should pay huge dividends) the cost attributed to avoidable patient medical errors is high.
One could make a reasonable argument that advanced treatments and high-risk procedures are responsible for some of these errors, but 40% of all nosocomial infections are related to catheter complications that result in UTIs. Our healthcare system has become complex. During the course of a typical hospital stay, a patient may interact with more than 50 caregivers creating hundreds of incidents (which can also be looked at as events) where information must be accurately communicated through team collaboration. When this does not happen the patient is placed in jeopardy.
Combine the inefficiencies in communication with the lack of real-time access to current and comprehensive patient medical information and it is no wonder why we fail so often to transition care smoothly. This information should be easily communicated and shared, real time, with key decision makers at the point–of-care and with all stakeholders in a timely and effective manner. In theory Computerized Physician Order Entry (CPOE), access to over 1,700 evidence based medicine guidelines and CDDS at the point of care should improve patient safety and outcomes at a reduced cost.
A step in the right direction to achieving zero errors would be transparent discussion of best practices through social networks built for healthcare to enable collaborating between teams of caregivers about a patient or a subject matter. Then we need to capture, review and communicate best practices in a systematic way as processes. When one considers that patient safety is a global concern, social networks that cast a broad net of inclusion and complete transparency could mitigate communication failures which the Joint Commission cites as the leading cause of medication errors, misdiagnosis, delays in treatment, and wrong-site surgeries, as well as the second most frequently cited root cause for operative and postoperative events.
Advances and adoption of EMR technology and data analytics will help to identify and isolate factors that contribute to medical errors such as bacterial rates due to ventilation, but until the healthcare community begins to embrace social collaboration for comparative analysis and quality improvement, patient safety will remain one of the biggest blemishes in the U.S. healthcare system.
That said, “zero accidents” may be a worthy goal after all.
