Injury prevention model may improve patient safety
A team of Medical College of Wisconsin researchers, led by Peter Layde, MD, professor of family and community medicine and co-director of the Injury Research Center, are proposing a new way to look at injuries that, they say, will be more useful in preventing them.
Their work appeared in the April 17 issue of the Journal of the American Medical Association. Most people in the medical field who have been working on this problem have focused on what could be called an error-reduction approach, which Layde refers to as the "name, blame, and shame approach."
That strategy is based on quality improvement principles used in manufacturing industries. It involves identifying errors as a means of preventing them. But Layde tells Healthcare Risk Management that the manufacturing approach has these limitations in the health care industry:
- It is often hard to identify when an error has occurred. Physicians reviewing a record may disagree about whether there was an actual error.
- Many injuries don’t occur due to an error. It could be a side effect of a medication or procedure which is preventable but not due to error.
- The error approach causes defensiveness because no one wants to be accused of an error.
"Our approach focuses on what could be done to prevent injury by looking at the whole chain of causation to find the weakest link," Layde says. "Then that link can be corrected. It may or may not be a person."
Don’t expect better behavior
Layde proposes using an alternative model to patient safety based on the principles of injury prevention that have been useful in public health to prevent other injuries. He says the model provides a theoretical framework and also some practical research tools for studying and improving patient safety.
He points out the dramatic reduction in injuries in manufacturing and transportation over the last 50 years using the same principles. An injury approach doesn’t look just at the injury event itself, but at the whole context in which the injury happened. It focuses on the agent of injury and the vehicle by which it was introduced.
He points out that injury-control approaches that try to modify a person’s behavior have not been shown to be very effective.
"You can’t reliably make everybody behave better," he says. For example, 40 years ago, fatalities in car accidents were much higher per 100,000 miles. The first approach was to try to educate people about driving drunk; that did little to reduce the toll. Later, when cars and highways were engineered to be safer, along with education, the toll dropped dramatically.
Here’s how Layde translates that into medical injury: If a patient is given the wrong medication, the consequences can be disastrous. The error model would focus on the person who gave the medication and punish him or her. That doesn’t get to the root cause in the system. In the injury-prevention model, the whole system of giving medication would be modified. One step might be computerized patient orders. That would prevent errors from illegible handwriting. The computer could check for drug interactions or patient allergies. A bar code on the patient’s wristband could be checked. Injuries would be prevented. All of these approaches are more effective than just trying to modify a nurse’s behavior.
"We are now doing some studies which implement this approach in different settings to identify risk factors and to monitor the occurrence of injuries," he says. "We are questioning the conventional dogma about the best approach to address patient safety. We want to encourage debate and discussion on the topic."
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