Tweet
STS: Approach to medical errors just doesn't fly, says
astronaut-physician Dr. Jim Bagian
THORACIC SURGERY UPDATE
Thoracic surgery is a specialty on the edge. Though physicians gathered
in Tampa for the 41st annual meeting of the Society of Thoracic Surgeons
(STS)
to discuss scientific breakthroughs in their rapidly changing field,
many who attended couldn't help but focus on issues outside of the
operating room.
Skyrocketing malpractice settlements and dwindling reimbursements have
taken a chunk out of the bottom line for many, while new technology means
surgeons are increasingly being elbowed out of the domain they once
ruled. Staff writer Heather Ennis was there and files the reports here.
The Medical Post
March 01, 2005
Volume 41, Issue 09
By Heather Ennis
TAMPA, FLA. - To make improvements in patient safety, health-care
organizations should strive to operate like a finely tuned . . . airplane?
That was the message Dr. Jim Bagian, an astronaut and physician, brought
to the Society of Thoracic Surgeons meeting here.
Fifty years ago, pilots had just about the most dangerous job you could
find, he said. They were paid well, but they frequently died. Though
there were 55 crashes for every 100,000 hours of flying time, it wasn't
the loss of life that prompted the industry to move toward better safety
practices, said Dr. Bagian. It was money.
"They said, 'We can't afford to keep building that many aircraft.' "
Similarly, financial pressures are finding their way into health care's
safety debate through huge malpractice settlements and government
funding programs that rise or fall based on hospital performance.
In aviation today, there are 1.97 mishaps per 100,000 flight hours, a
considerable improvement since the 1950s .
Despite significant public and government pressure, health care has not
seen similarly dramatic improvements in patient safety, said Dr. Bagian.
"We're talking about whole-number percentage loss rates, and they're
talking about one in a million. We don't have nearly the fervour or
dedication to address these issues."
The key to air travel safety is redundancy, said Dr. Bagian. When proper
procedures are followed, catastrophic events have a tough time getting
around the system.
"Even though aircraft engines are extremely reliable, they have this
redundancy so the system can fail and you still get to where you're
going," he said. "In medicine, we don't have that redundancy."
A single mistake in medicine is often followed through to its most
unfortunate conclusion, despite the fact there are usually warning signs
along the way, said Dr. Bagian. The problem is, the culture of health
care is not friendly to those who speak up about safety issues.
"People keep their mouths shut if they see something going on until
they're absolutely sure they're right," he said. "We don't respond in a
positive way. It's intimidating."
The culture of silence is the first thing that needs to change, said Dr.
Bagian, and it has to happen from the ground up. There should be no
limitations on who can report possible safety issues.
It's wrong to think things only need to be reported once they have
already happened, added Dr. Bagian. The most important incidents are the
close calls, which can fuel change without people getting hurt.
"Close calls happen all the time; they change your behaviour," he said.
"We already have plenty of accountability systems - we need learning."
Organizations also need to set aside the antiquated notion that the
human element is what facilitates errors.
"People don't come to work to hurt someone or make a mistake. They don't
say, 'How do I screw up today in a new and creative way?' "
To get safer, systems need to evolve in ways that make it harder for
mistakes to happen, he said. Responding to errors by paying lip service
to safety and writing new rules that are ignored isn't good enough.
"Very often, those superficial solutions are what people try to
implement," said Dr. Bagian. "Trying harder doesn't get it done. You're
talking about a cultural change."
http://www.medicalpost.com/mpcontent/article.jsp?content050224_185151_3552
astronaut-physician Dr. Jim Bagian
THORACIC SURGERY UPDATE
Thoracic surgery is a specialty on the edge. Though physicians gathered
in Tampa for the 41st annual meeting of the Society of Thoracic Surgeons
(STS)
to discuss scientific breakthroughs in their rapidly changing field,
many who attended couldn't help but focus on issues outside of the
operating room.
Skyrocketing malpractice settlements and dwindling reimbursements have
taken a chunk out of the bottom line for many, while new technology means
surgeons are increasingly being elbowed out of the domain they once
ruled. Staff writer Heather Ennis was there and files the reports here.
The Medical Post
March 01, 2005
Volume 41, Issue 09
By Heather Ennis
TAMPA, FLA. - To make improvements in patient safety, health-care
organizations should strive to operate like a finely tuned . . . airplane?
That was the message Dr. Jim Bagian, an astronaut and physician, brought
to the Society of Thoracic Surgeons meeting here.
Fifty years ago, pilots had just about the most dangerous job you could
find, he said. They were paid well, but they frequently died. Though
there were 55 crashes for every 100,000 hours of flying time, it wasn't
the loss of life that prompted the industry to move toward better safety
practices, said Dr. Bagian. It was money.
"They said, 'We can't afford to keep building that many aircraft.' "
Similarly, financial pressures are finding their way into health care's
safety debate through huge malpractice settlements and government
funding programs that rise or fall based on hospital performance.
In aviation today, there are 1.97 mishaps per 100,000 flight hours, a
considerable improvement since the 1950s .
Despite significant public and government pressure, health care has not
seen similarly dramatic improvements in patient safety, said Dr. Bagian.
"We're talking about whole-number percentage loss rates, and they're
talking about one in a million. We don't have nearly the fervour or
dedication to address these issues."
The key to air travel safety is redundancy, said Dr. Bagian. When proper
procedures are followed, catastrophic events have a tough time getting
around the system.
"Even though aircraft engines are extremely reliable, they have this
redundancy so the system can fail and you still get to where you're
going," he said. "In medicine, we don't have that redundancy."
A single mistake in medicine is often followed through to its most
unfortunate conclusion, despite the fact there are usually warning signs
along the way, said Dr. Bagian. The problem is, the culture of health
care is not friendly to those who speak up about safety issues.
"People keep their mouths shut if they see something going on until
they're absolutely sure they're right," he said. "We don't respond in a
positive way. It's intimidating."
The culture of silence is the first thing that needs to change, said Dr.
Bagian, and it has to happen from the ground up. There should be no
limitations on who can report possible safety issues.
It's wrong to think things only need to be reported once they have
already happened, added Dr. Bagian. The most important incidents are the
close calls, which can fuel change without people getting hurt.
"Close calls happen all the time; they change your behaviour," he said.
"We already have plenty of accountability systems - we need learning."
Organizations also need to set aside the antiquated notion that the
human element is what facilitates errors.
"People don't come to work to hurt someone or make a mistake. They don't
say, 'How do I screw up today in a new and creative way?' "
To get safer, systems need to evolve in ways that make it harder for
mistakes to happen, he said. Responding to errors by paying lip service
to safety and writing new rules that are ignored isn't good enough.
"Very often, those superficial solutions are what people try to
implement," said Dr. Bagian. "Trying harder doesn't get it done. You're
talking about a cultural change."
http://www.medicalpost.com/mpcontent/article.jsp?content050224_185151_3552