Kaiser Permanente Ramps Up Patient-Safety Efforts

OAKLAND, Calif. -- Recently in a California Kaiser

Permanente hospital, an expectant mom came in for her planned C-section. She

was healthy and her unborn baby was healthy; two good signs noted by her

medical team. But, in a matter of minutes, the healthy mom-to-be began to

gasp and struggle for each breath. An emergency C-section was called.

Suddenly, the mother stopped breathing; the baby was in distress. The

possibility of losing two lives became frighteningly real. But that didn't

happen.

Today, mom and baby are fine because this Kaiser Permanente medical staff

had gone through Critical Events Team Training (CETT), the hands-on training

that uses computerized life-sized mannequins to practice teamwork and

communication in stressful operating room situations. It is an important

feature of Human Factors, a program that has been adapted to healthcare from

the aviation industry where it was successful in reducing errors.

The Institute of Medicine's 1999 groundbreaking report, "Too Err is Human"

generated unprecedented attention on the need for patient safety. "The IOM

report spurred a national call-to-action to improve patient safety," said

Suzanne Graham, RN, PhD, patient safety leader for California regions.

Encouraged by the IOM Report, Kaiser Permanente began a sweeping patient

safety initiative used to develop a culture of safety. Innovative programs

include:

-- Human Factors

* The Critical Events Team Training cited above is part of the

Perinatal Patient Safety Project and uses communication and training

tools based on Human Factors.

* Pre-Operative Briefings brings together all members of the surgical

team to make sure they understand about what will be done throughout

the surgical procedure.

-- Situation, Background, Assessment, Recommendation (SBAR)

* A brief, to-the-point, way of communicating important medical

information that was adapted from US Naval Operations is being

introduced.

An important element of Kaiser Permanente's patient safety program is

reporting errors and near misses.

"Most errors are caused by good, caring, competent individuals that do not come to work saying, 'today I'm going to make the mother of all errors,'" said Graham. "But there are human limitations and errors happen. At least 80 percent are system errors but they are

often blamed on the last one to touch the patient. Here at Kaiser Permanente,

each medical center now has a policy that supports the reporting of errors and

near misses so we can learn from our mistakes and focus on correcting

systems."

Kaiser Permanente is America's leading integrated health plan. Founded in

1945, it is a non-profit, group practice prepayment program with headquarters

in Oakland, California. Kaiser Permanente serves the healthcare needs of over

8.2 million members in nine states and the District of Columbia. Today it

encompasses Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals

and their subsidiaries, and the Permanente Medical Groups, as well as an

affiliation with Group Health Cooperative based in Seattle. Nationwide, Kaiser

Permanente includes approximately 136,000 technical, administrative and

clerical employees and 11,000 physicians representing all specialties.

Source: Kaiser Permanente

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