Preventing Medical Errors: Avoid Blame Game but Punish Habitual Offenders
Patient safety experts at Johns Hopkins and elsewhere are taking their prescription for avoiding medical errors in hospital care one step beyond already successful “no-fault, no-blame” approaches, now calling for penalties for doctors and nurses who fail to comply with proven safety measures. Penalties should only apply, these experts say, when current no-blame practices designed to prevent recurrences stall and, after warnings and counseling, have failed to change healthcare workers’ behavior.
“Our preference during the last decade for not assigning blame to individuals went a long way to encourage the disclosure of medical errors and getting buy-in for the idea that systemic safety problems existed and could be fixed,” says anesthesiologist Peter Pronovost, MD, PhD, a patient safety expert at Johns Hopkins.
“But despite making systems safer and counseling staff on best practices, mistakes continue to happen, so it’s time to add some accountability and enforcement policies to address and stop unsafe practices,” he says.
Pronovost makes his case, along with fellow patient safety expert Robert Wachter of the University of California, San Francisco, in a recent issue of The New England Journal of Medicine. The pair bases their call on the estimated 100,000 yearly deaths in the United States from infections picked up by people while undergoing treatment, most often in hospitals.
In their report, Pronovost and Wachter suggest penalties that they say could serve as a starting point for implementing an accountability system to run parallel with the no-blame approach for four common but avoidable medical errors.
Healthcare workers who persistently fail to wash their hands before entering a patient’s room, for example, would be required to undergo mandatory training and reeducation classes and lose their patient care privileges, with loss of pay, for one week. Repeated failings by surgeons to conduct a “time out” prior to surgery would result in retraining sessions and a loss of access to the operating room for two weeks, with a commensurate loss in pay. Repeated failure to use and sign surgical checklists when inserting catheters would be similarly punished.
To support their approach, Pronovost and Wachter cite several examples in which the no-blame approach has been successful only up to a certain point in correcting unsafe hospital practices and lowering the number of unintended mistakes in patient care.
Included in this list are computerized systems to reduce medication errors caused by sloppy doctors’ handwriting or similar-looking drug packaging, requirements that surgeons mark the site of an operation and perform time-outs to double-check plans to stop wrong-site operations, and the placement of disinfectant hand gel dispensers outside patient rooms to encourage hand hygiene.
The pair also lays down eight principles to determine whether punishments are warranted. Among them: Initial efforts must have been made to resolve underlying systemic problems that contribute to medical error; and retraining and counseling must have been tried.
“Above all else, physicians and other healthcare providers need to recognize that the main reason to find the right balance between no blame and individual accountability is that doing so will save lives,” says Pronovost.
— Source: Johns Hopkins Medicine
Partnership to Provide RAC Tracking and Denial Management Services
Panacea Healthcare Solutions, LLC recently announced that it has chosen to offer H.I.M. ON CALL’s RAConciliation solution as the exclusive RAC tracking and denial management module at Panacea’s RACAuditor.com Web site.
RAConciliation is a Web-based system that features an audit-tracking and denial prevention approach that will assist hospitals, physicians, and outpatient facilities with tracking all cases requested, submitted, reviewed, determined, and appealed and providing the final outcome of each case.
By implementing RAConciliation, hospitals will be able to track and reconcile in a timely manner all types of external reviews coming from third party payers and governmental regulatory agencies and trend all outcomes for implementation of corrective actions.
— Sources: Panacea Healthcare Solutions, LLC; H.I.M. ON CALL
Reilly Named COO for TRS Institute
The TRS Institute (TRSi), an employer-owned medical transcription training program, has announced the promotion of Peter Reilly to chief operating officer. Formerly, Reilly held the position of vice president of sales, marketing, and business development for TRS, responsible for the development, stewardship, and expansion of the TRSi brand.
In his new position, Reilly will be responsible for the operation of the online and on-site medical transcription/speech recognition training programs, as well as transcription services offerings and all components supporting those efforts, including accounting, human resources, IT, and sales and marketing.
— Source: TRS Institute
Heartland Information Services Appoints New CEO
Heartland Information Services, a national provider of full-service medical transcription services, has promoted Brett S. Himes to president and CEO. Previously chief operating officer and chief financial officer (CFO), Himes will assume the new position immediately.
Prior to joining Heartland in August 2007, Himes was executive vice president and CFO of SourceOne Healthcare Technologies, the largest radiology supplies distributor in the United States. Prior to that, he spent six years with McKesson, where he was vice president of finance of the supply management business and then senior vice president and CFO of the medical-surgical business.
— Source: Heartland Information Services