Understanding Patient Safety: A Q&A with Robert Wachter, MD

Robert M. Wachter, MD, a professor of medicine, chief of the medical service and chair of the patient safety committee at University of California, San Francisco (UCSF) Medical Center, has been a central figure in educating the medical community and general public about pressing safety issues in healthcare institutions. Wachter has written prolifically on this topic, including the bestseller, "Internal Bleeding: The Truth Behind Americas Terrifying Epidemic of Medical Mistakes." His new book, "Understanding Patient Safety," was published by McGraw-Hill last October.

Q: What prompted you to write "Understanding Patient Safety?"

A: I get asked all the time to recommend a lively, engaging and evidence-based introduction to the field of patient safety written with a clinical slant. I couldnt find a book that fit the bill, so the time seemed right to write one.

Q: What has had the biggest impact on patient safety in the last five years?

A: The first step was awareness. Beginning with the publication of the Institute of Medicine report on medical errors in 2000, we now recognize how serious the problem of medical errors is how many people are harmed and killed each year from medical mistakes.

We also have discovered that our old approach to errors just try to be really, really careful was hopelessly flawed. So I think the combination of increased attention and a new approach, known as systems thinking, has made the largest difference.

Q: What is the most common medical error occurring in healthcare institutions today?

A: Most errors relate to poor communication, between doctors and other doctors, between doctors and patients, between nurses and pharmacists, you name it. These communication glitches result in medication errors, surgical errors, radiology errors and more.

Q: Have advances in medical technology helped to minimize or increase the number of medical mistakes?

A: Both. On the one hand, technology is helping to decrease errors, such as through the use of computerized medical records, computerized order entry, and bar coding. Even relatively simple technologies that we dont think of as safety oriented text paging, portable ultrasound for catheter insertion or drainage of fluid from the abdomen or thorax are actually saving lives. On the other hand, technology has made medicine much more complex, and therefore created many new errors. MRI scans are spectacular, but we didnt have to worry about tanks of oxygen being converted into potentially fatal projectiles before we had scanners with powerful magnets.

Q: What future trends do you see emerging in the realm of patient safety and medical errors?

A: Computerization has clearly reached the tipping point within a decade, it will be very unusual to find a hospital or large doctors office that still relies on pen and paper. Were finding that IT (information technology) improves safety in many ways, but that weve introduced a whole slew of unanticipated consequences, including some new classes of errors. The recognition of the critical importance of culture in safety is another major trend, with lots of effort going into trying to improve teamwork and collaboration.

Simulation is beginning to take off. More attention is being paid to the importance of a well rested, well trained workforce. The residency duty hour limits of 80 hours a week are only the start. And the increased public attention to medical errors is leading to much more public reporting. There are truly 1,000 flowers blooming when it comes to safety.

Q: What is the best advice/encouragement you can provide to operating room nurses and other members of the surgical team regarding how they can play an active role in championing patient safety?

A: We finally have come to understand that healthcare is a team sport, and that having a system that depends on the perfection of humans is not a safety system. Rather, safe care only happens when competent providers function as members of a team, when thoughtful rules and standards are followed, when information technology is leveraged to help when it can, and when everybody knows that they are one slip or bad break away from a devastating error. If I had to focus on one or a couple of things, Id advise them to speak up when they think something is wrong not just when they know something is wrong, and to look for error prone situations and see them as opportunities for improvements, not workarounds.

Q: As you know, CMS has made it clear that certain infections and other adverse events/conditions can be prevented through evidence-based practice; how do you think the new CMS mandate/pay-for-performance policies will affect healthcare practitioners focus on upholding patient safety, examining their practices, and using risk management strategies?

A: As I recently described in an article in the Joint Commission Journal on Quality and Safety, I think the new CMS no pay for errors policy is a clever strategy to get providers and institutions to focus on patient safety practices. It is no coincidence that so many of the initial no pay adverse events are infections, since the rules of this particular game are to find adverse events that can be measured and (with the reliable adoption of evidence-based practices) can be largely prevented. There will undoubtedly be some gaming and unintended consequences (for example, Medicare will pay if the adverse event is present on admission, so now well be doing backflips to prove that the patient already had some dings before they came in, just the way the Hertz guy looks over your car before you drive it off the lot), but overall I think this direction is a good one. One lesson of the past decade is that we will not put the energy and resources into safety and quality until there is real skin in the game.

Q: You address creating a culture based on patient safety in a nutshell, what are the best ways to achieve this particularly in the OR, where resistance to change is frequently encountered?

A: First of all, providers need to understand that their old ways of doing business, even though they seemed right at the time, take us and our patients down dark alleys. I wrote my book, "Understanding Patient Safety," in part to provider all kinds of providers with the information they need to understand the hazards of medical care and how our new understanding of systems can help us prevent them. Leadership is incredibly important and even in a relatively unenlightened medical staff, there are undoubtedly some respected clinicians who get it. They need to be trotted out at every opportunity. Telling stories is key; data are useful but the stories are what motivate all of us to do things differently. This is why I tell dramatic stories of errors in virtually all my writing and speaking about patient safety. Analogies from other industries can help, but dont take them too far: medical care is far more complex than flying an airplane from Los Angeles to San Francisco, or delivering a package by tomorrow morning. Finally, many of us are experimenting with things like interdisciplinary, scenario-based teamwork training to try to move things along. I think it will help. What wont work: emails and memos to busy people telling them to change your culture!