Officials say state has made a few, but there’s a long journey ahead
ALLISON RUPP Star-Tribune staff writer | Posted: Thursday, April 3, 2008 12:00 am
LARAMIE - Creating a viable reporting system for medical errors stands out as a key to improving patient safety, state and national officials said in Laramie Wednesday.
Both medical and legal professionals met at the new University of Wyoming Convention Center to discuss ways to improve patient care. The Wyoming Law Review's annual symposium runs through today, and this year's topic is health care reform and patient safety.
Even though state law mandates that every licensed health care facility in the state must report medical errors to the state Department of Health, members of the health care profession have said that's not happening.
To improve patient safety, Dr. Allen Kachalia told conference participants that health care needs a systems level of improvement, not an individual level; an increased culture of safety; more detailed data on errors; and greater transparency of what goes on when an error occurs.
Kachalia, an academic hospitalist at Brigham and Women's Hospital in Boston, also holds a law degree.
During his presentation, the first of the day, Kachalia said improving patient safety involves the legal system. He said the legal system can provide resources and infrastructure that might not otherwise be available.
"They can set up a viable reporting system that everyone wants to use," Kachalia said.
Right now, most states, including Wyoming, have some type of law about reporting medical errors. However, Kachalia said these laws catch only the most severe errors and there is no incentive for hospitals to actually report anything.
He said there needs to be a reporting system that documents all errors and even near-misses. It also must provide protection to providers for reporting the errors.
He added that reporting shouldn't be mandated. It should be voluntary and come from internally.
The current legal system assigns responsibility to an individual instead of a health system, which health care providers said needs to change.
"Every provider stands alone when something goes wrong. It's not the way to go," said Dr. Jack Glode, a Cheyenne cardiologist. "If you have institution liability instead of individual liability, it forces physicians to be accountable to each other."
Besides open reporting, Lauree Barreca, a litigator for John Hopkins Health System in Baltimore, said there needs to be an open dialogue about the errors that do occur.
If a medical error reaches the legal arena, Barreca said, the information gets shut in a file usually in an attorney's desk.
"Everyone goes into shutdown, and no one talks about it," Barreca said. "We're not looking at patient safety, we're looking at how we can defend a physician. We're not learning from mistakes."
Aaron Bieber, a third-year law student at UW, said the Law Review wanted to bring medical and legal professionals together at this year's legal symposium to see what ideas were feasible to improve patient safety and what to do when a medical error occurs.
"We wanted to look at how the medical side needs to change and what the implications of that will be for the legal community," Bieber said.
In his opening remarks, the president of the university assured people this conference was not about tort reform. He said it was about bridging the gap between the medical and legal professions.
"I didn't know our health sciences dean was testifying at a trial in Cheyenne," Tom Buchanan said. "I think that's proof of the connection."
Glode called the tort reform debate Wyoming experienced three years ago "a suffering" and said it "was unproductive and actually destructive."
LARAMIE - Before attending medical school and becoming a family practice doctor in Buffalo, Dr. Larry Kirven worked in machinery.
Walking into work, he would see a huge sign that said, "Safety First." The hard hats and equipment he used had stickers on them reminding the workers about safety.
It's not like that in hospitals and doctors' offices, Kirven said.
"You don't walk into a hospital and see such a prominent display of safety," he said.
Kirven and several other health care professionals spoke Wednesday about the culture of hospitals and how it doesn't always speak to the improvement of patient safety.
They spoke at this year's Wyoming Law Review Symposium, "Health Care Reform & Patient Safety: Challenges and Opportunities for Medicine and the Law."
Some hospitals might hesitate to publicize their ideas about safety because they don't want patients to realize mistakes happen, Kirven speculated. However, patients should feel encouraged if they see a "Safety First" sign hanging in the lobby of a hospital.
"We keep the fact quiet that bad things happen here," Kirven said. "We need a change in the culture of medicine to one that is open to adapting and changing our way of thinking."
A commitment to a culture of safety is literally written on the walls of the buildings in John Hopkins Health System.
Pictures of staff members hang on the walls with the five steps to good hand washing to remind employees to wash their hands often and show them it is a priority, said Lauree Barreca, a litigator for John Hopkins Health System in Baltimore.
The Law Review brought Barreca and her colleague, Meg Garrett, to talk about how they began to change the culture of their hospital after a medication error killed an 18-month-old in 2001.
They shared strategies with the room full of Wyoming health care providers and lawyers.
Building trust among employees is crucial when trying to improve safety, Barreca said. The administration needs to create an environment where employees feel comfortable sharing concerns and encourage them to speak up when something goes wrong.
"Let them know they are not someone who is tattling," Barreca said.
John Hopkins teaches employees the message of safety from the minute they begin orientation, which every staff member has to complete.
"The safety message really is number one," Barreca said. "We tell them that this is a culture of safety and they are part of the safety team."
This team includes everyone from the housekeepers to the chief executive officer.
The hospital created "safety rounds" in which top administrators visit the floors looking for problems.
John Hopkins has a patient safety committee, tracks all errors electronically and publishes a patient safety newsletter where providers discuss errors.
Even though John Hopkins Health System employs more physicians than work in the entire state of Wyoming, Barreca and Garrett said these are strategies any hospital can use.
To help some of the smaller hospitals that might not have enough staff to devote people to patient safety teams, Kirven proposed creating a state patient safety organization.
This type of organization, which the Wyoming Healthcare Commission hopes to introduce into legislation next year, would offer coordination among all safety efforts going on across the state and provide analysis.
"It will teach people not to make that error again," Kirven said.
Dr. Brent Sherard, director of the Wyoming Department of Health, said the commission must be careful in how it defines such an organization.
It should serve as an organization that provides information and doesn't offer punitive judgments on medical errors, he said.
Whether it involves a state safety organization or not, changing the culture of hospitals is key to improving patient safety, Kirven said.
"We are talking about this because it saves lives."