Issue Brief

November 2000

Patient Safety and Medical Errors - Part II

This Issue Brief  focuses on efforts being made by the Department of Veterans Affairs (VA) to improve quality and safety in their medical system. Many of these efforts were initiated by Dr. Kenneth Kizer when he was Under Secretary for Health at the VA. Dr. Kizer was a guest of NIHP last fall. You may be interested in reviewing the statement he made at that time, which can be found on our web site at www.nihp.org  It is our goal of the National Institute of Health Policy to promote better health care through better policy.  Our purpose in sending out this newsletter is to inform people about current health policy issues. We hope it is helpful to you. 

I.  What is the Government Doing to Improve Patient Safety?
In the last Issue Brief  I discussed some of the things that need consideration, together with current efforts being made to improve patient safety and reduce medical errors.  Today, I think it would be helpful to take an in-depth look at what the federal government is doing in some of its facilities and see how these efforts could help lead the way to safer practices in other medical settings.

II. Battling Errors in the Department of Veterans Affairs Health System
In its landmark report, To Err is Human: Building A Safer Health System, the Institute of Medicine concluded that the vast majority of preventable medical errors are not due to incompetence or carelessness on the part of individual doctors, nurses, or other workers; instead, it concluded that perhaps as many as 95% are “system errors.” That means that most mistakes are directly related to procedures, equipment, job designs, communication systems, and other elements in the work environment. Safe health systems, like safe aviation, must be designed to consider the incidence of human error and still achieve reliable outcomes.

The VA operates 173 medical centers and treats approximately 2.5 million people every year. It has been working on improving safety in its system for several years. From its broad reaching 1995 proposal to transform the VA culture and “engineer in” quality, to its increased use of safety technology (e.g., bar coding for patient identification and blood transfusions) the VA has initiated many efforts to improve patient safety. It has developed a national patient safety registry, a patient safety improvement handbook, patient safety centers of inquiry and numerous other patient safety initiatives.

Recognizing that patient safety is not its concern alone, the VA launched the National Patient Safety Partnership—a public-private consortium of organizations with a shared interest in improving patient safety. In addition to the VA, charter members include the American Medical Association (AMA), the American Hospital Association, the American Nurses Association, the Joint Commission of Accreditation of Healthcare Organizations, the Association of American Medical Colleges, the Institute for Healthcare Improvement and the National Patient Safety Foundation at the AMA in healthcare. (For example, it was the through the NPSP’s efforts that the FDA established a clearinghouse for information related to the effect of Y2K computer issues on medical devices.)

III. The VA’s Root Cause Analysis System
But perhaps its most challenging, difficult, and promising effort is the VA’s attempt to develop a system of root cause analysis to learn from mistakes and near misses.  Root cause analysis is intended to get at the source of a problem and then redesign the system to prevent similar mishaps from occurring in the future.

In this process, when an adverse event or a close call is reported, the hospital director selects a team of three to five persons to ferret out the cause of the problem and any contributing factors. (An adverse event is an injury resulting from a medical intervention – it may or may not be caused by an error. A close call is a situation that would have resulted in an adverse event if not for quick action or sheer good luck.) Within a few days the team compiles a report and shows it to the person who first reported the problem. That person is asked to confirm the findings documented in the report.  By returning to the original source of information and including that person’s view in the final report they hope to establish credibility and increase the likelihood that their results will be used for quality improvement and error prevention. Obviously, this program requires good reporting if it is to work well.

Dr. James Bagian, a former space shuttle astronaut, was hired to lead VA hospital employees in this effort.  Dr. Bagian, as one of the lead investigators of the 1986 Challenger space shuttle disaster, is no newcomer to analyzing systemic errors.  His challenge is to win converts to the new patient safety program among VA employees and to ensure the success of the root cause analysis process within the system. The program features mandatory and voluntary reporting of errors and close calls. In designing this reporting system, the VA was assisted by experts in the safety field such as Dr. Charles Billings, one of the founders of the Aviation Safety Reporting System. Along with other experts from NASA and the academic community, he advised the VA that an ideal reporting system

·        must be non-punitive, voluntary, confidential and de-identified,

·        must make extensive use of narratives,

·        have interdisciplinary review teams, and;

·        most importantly, focus on identifying vulnerabilities rather than be a counting exercise.

The VA is using these principles to design a patient safety reporting system. Last November, this new reporting system was pilot-tested in Veterans Integrated Service Network 8, which includes 21 facilities in Florida, South Georgia and Puerto Rico. Extensive training, constant mentoring, and feedback are required to assure full understanding the root cause and redesign of the system. The managers and clinicians using the system believe it will make a significant improvement in the care of veterans. The VA is now expanding the system with the intent of implementing it in all VA medical centers.

To complement its internal system the VA has also entered into an agreement with NASA to establish the Patient Safety Reporting System (PSRS). This is a complementary, de-identified reporting system modeled after the highly successful Aviation Safety Reporting System operated by NASA on behalf of the Federal Aviation Administration. It is external to the VA and allows all doctors, nurses, pharmacists, laboratory personnel, and others to report unsafe occurrences without fear of action being taken against them. The VA has already implemented several changes based on lessons learned from the review of adverse events.

IV. Educating for a Culture of Safety
In addition, the VA has developed a new curriculum on safety. It plans to provide education and training on patient safety not only to those already in practice, but also at the medical, nursing, and health professional school levels. This marks the first occasion that an extensive safety curriculum has been developed and broadly implemented. Dr. Bagian feels the VA is particularly well-situated to lead an educational effort because it plays a major role in the education of health care professionals in the United States. The VA is affiliated with 105 medical schools, 54 dental schools and 1140 other paraprofessional schools. Each year 100,000 health professionals receive training in VA medical centers and up to one-half of all physicians in the country train in a VA facility during medical school or residency.

The VA surveyed its employees to gain understanding concerning the best way to re-train its employees and change its culture. One of the more interesting findings of that survey was that the shame of making an error appeared a more powerful inhibitor of reporting errors than fear of punishment. The survey showed that employees were intolerant of their own errors and were “ashamed” if others knew that they had made an error. People with strong feelings of shame are less likely to exchange learning experiences with others, thus reducing the opportunity for the entire system to learn from those experiences.  Training and encouraging individuals so inclined  to report mistakes will prove a major challenge.

V. Will the VA Succeed?
It is too soon to tell whether the VA will be successful in its ambitious efforts to improve patient safety. The first challenge, and perhaps the greatest, is to involve all of its employees in the commitment to changing its culture. According to testimony by the Government Accounting Office (GAO) before the House Veterans Affairs Committee last July, there has been little participation by senior management in the VA’s patient safety training programs. So far, most of the 600 employees trained by the VA were facility risk managers or quality managers. If the VA really wants to succeed in changing its culture, medical center directors will need to be involved in its training programs.

A second challenge that will surface as this program unfolds is the need to deal with the increased number of reports of adverse events. There is a substantial amount of underreporting in almost all medical institutions today, so if the VA program is truly successful at changing its culture, it should see an increase in the number of reported errors. That does not necessarily mean more errors are occurring, it merely means the reporting system is beginning to work.  In this instance, there will be real opportunities for improvements throughout the system. Unfortunately, the VA functions in a political world and as this information makes its way into the media the VA could see some very rocky times. Getting through this part of the process will require all the skills the VA leadership can bring to bear.

VI. Is the VA a Model for Other Healthcare Institutions?
The short answer is, not yet.  But, the VA’s patient safety program has not been fully implemented and when it is, it may very well prove to be a model. Many of the VA’s safety initiatives are exemplary, but they are stand-alone changes that preceded this current effort to create a system-wide culture of safety. The VA has now gone beyond those initiatives and has taken bold steps to create an entire culture change for enhancing patient safety.

While they are still in the early stages of this effort, according to the GAO they lead the rest of the healthcare sector in adopting the right concepts and consulting with the right people. As Dr. Bagian says, “The only way to reduce risk is to be mindful of it every day. In aviation, after every flight, the crew sits down and goes over what happened. In medicine, it’s not done. My astronaut friends look at me and say, ‘You have to explain that to people?’”  The rest of the American healthcare system should benefit greatly from watching the VA as it moves forward with its aggressive new effort.