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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
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
-- 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
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
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