JCAHO considers new standards to reduce errors
Experts stress importance of prevention
Coming soon from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO): new standards that require hospitals to take a proactive stance regarding medical errors.
"When it comes to risk reduction, the rule of thumb has been to do our best.’ The idea is, if we’re competent, bad things won’t happen by mistake. When bad things did happen, the tendency was to say it’s because they couldn’t be avoided or the person involved was not conscientious. The solution was to do something to that person."
So says Paul Schyve, MD, senior vice president of JCAHO. "Two things occurred to change all this," he explains. "First, in 1995, the media started to report on the more shocking medical errors, such as amputating the wrong foot or administering an overdose of chemotherapy that killed a patient.
"Next came the Institute of Medicine report that noted 48,000 to 90,000 hospital deaths a year from medical error."
Both situations induced public alarm and led the health care industry to re-evaluate their performance, become sensitive to medical error, conduct extensive root-cause analyses, and look into ways to prevent further error.
"But health care does not need any more error detection," claims Clark Carboneau, certified quality manager at Great Plains Regional Medical Center in North Platte, NE. "It’s been coming out of our ears for 20 or 30 years. What we need is to move to error prevention."
And that’s what Schyve says the organization will be expecting from hospitals, probably by next year. "JCAHO is now beginning the review process for a draft standard that would require a proactive risk reduction program," he says. "The proposed revisions in standards would have you itemize what you are doing proactively."
There are five points that Schyve expects to see incorporated into the new standard:
- Put more emphasis on leaders creating an environment in which people will feel comfortable reporting not just bad things, but near misses. "People need to feel safe talking about this."
- Educate the staff to think about safety: What is the safe thing to do and how can we do it even more safely?
- Put in place a program that is proactive. "The example that we use is what engineers call failure mode and effective analysis. What are the processes that might lead to a problem? Let’s take a close look at these processes," Schyve says.
- Add the word safety to standards that talk about quality. "We’ve always defined one of the dimensions of quality as safety. But we thought that by breaking out the word separately, it heightens attention to this," he says.
- Require patients and families to be informed about any unanticipated serious outcomes.
"Those [points] were designed specifically for hospitals," Schyve explains, "and our process is that they go through internal committees, then are sent out for field review to professional organizations and consumer groups for feedback and modifications. Finally, they come back through JCAHO internal committees to be adopted."
Carboneau asks, "How can we make these processes so robust that there is no possible way an error can be made? It’s doable for the airlines and for the space industry, and it can be doable for health care, too."
The approach used by engineers today begins by looking at the potential for error. For instance, the aerospace industry will bring in military pilots to assess the configuration of a new fighter jet. The pilots may point out that the handle for a pilot ejection is in an awkward place, certain instruments are too small to be read easily, or the pilot seats would be uncomfortable for long distance flying.
In this way, the problem is identified before the plane ever leaves the ground, and adjustments are made so that the potential for error is eliminated.
These methods of anticipating error and correcting that possibility before it happens is what both Schyve and Carboneau are talking about.
Carboneau says, "Quality professionals should learn to ask themselves, How can the process be changed so that it will be impossible to make a mistake?’"
One example of mistake-proofing involves drug packaging. Carboneau cites "the pharmaceutical company that changed the packaging of the antibiotic gentamicin. In the past, this drug was packaged with several doses in one container so it was convenient for the pharmacist." It was also easy to overdose a patient if the caregiver thought the contents contained a single dose. "Now only one dose is packaged per container, thereby eliminating the possibility of an overdose," he explains.
A similar episode in a Denver hospital, where two different medications packaged in similar colors and design were sitting side by side on the pharmacy shelf. When a physician ordered medication A, the pharmacist inadvertently grabbed the look-alike medication B. The mix-up caused a patient coming out of anesthesia to be anesthetized more deeply instead. It didn’t result in disaster, but was a scary near miss.
Needless to say, the medications were widely separated after that, but if the potential for error had been identified earlier with a proactive program of error reduction, the incident would never have happened.
"Mistakes are avoidable," says Carboneau. "We don’t have to live with them. Waiting for something to happen is not the answer. I’m for anything the Joint Commission can do to error-proof our industry."
Schyve agrees. "We need to think about how we design the processes in the beginning so they will be less error-prone. We should turn to engineers and what they do in building things like NASA. They try to think things through when they’re building something. They can’t wait for a disaster to happen far above the earth, so they ask themselves, What could go wrong? How critical could this situation be? How can we prevent it?’"
The health care industry needs to take the same approach, according to both Schyve and Carboneau. "Proactively," Schyve says, "the concept is to say, Let’s look at this process. What are the potential bad outcomes? What do we need to avoid? Let’s make this a good process. What are the steps of risk in the process, and how can we redesign this to avoid bad results?’"
He expects JCAHO’s new standards on proactive error reduction to be in place by January 2001.
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