by Sean Power
November 27, 2013
In 1999, the Institute of Medicine (IOM) reported that anywhere from 44,000 to 98,000 people die in American hospitals because of medical errors. The IOM also found that 90 percent of these deaths are the result of failed systems and procedures.
John T. James, founder of Patient Safety America, recently researched whether the IOM figures from 1999 were still accurate estimates. The study, published in the Journal of Patient Safety, found that between 210,000 and 440,000 patients each year suffer preventable harm—not the 44,000 to 98,000 previously researched by the IOM.
If Mr. James’ figures are accurate—which many critics believe is the case—that would make medical errors the third-leading cause of death in the United States.
Last year, The Huffington Post recently published an article about Alice Brennan, 88, who died as a result of preventable harm, reminding readers that real individuals make up these aggregate statistics, and that hospitals should strive to eliminate medical errors regardless of whether the total is 44,000 or 440,000, or any number in between.
When errors are committed and they result in either a near miss or an adverse event, disclosure to the patient poses legal and ethical questions. Those questions are beyond the scope of this article.
Instead, this post outlines how checklists can help communicate errors with patients.
In a May article on The Doctor Weighs In, I discussed the safety benefits of adopting checklists. Here, I outline the role checklists play in keeping patient safety at the heart of disclosure.
If 90 percent of deaths at hospitals caused by error are the result of systemic and procedural failure, as reported by the IOM in 1999, then checklists can prove useful in both preventing errors and explaining why the error occurred at all.
According to Peter Pronovost, M.D., Ph.D., FCCM (Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient):
“To be accountable for patient harms, health care needs valid and transparent measures, knowledge of how often harms are preventable, and interventions and incentives to improve performance.”
Checklists can help strengthen systems and improve compliance to procedures. Here are a few more ways they can help with error disclosure and reporting.
1. Checklists ensure best practices are followed, reducing the likelihood for systemic or procedural failure.
When checklists are followed the chance for error is reduced. Even when things go wrong, checklists provide a resource for explaining the steps that were taken to prevent the error to patients and families. They can also help to illustrate the safeguards in place to prevent or mitigate adverse consequences.
For instance, the PCA Safety Checklist is offered as a free resource by the Physician-Patient Alliance for Health & Safety. It was developed by a multidisciplinary team of experts to minimize adverse events associated with patient-controlled analgesia (PCA).
The checklist sets out to minimize adverse events and maximize patient safety and health outcomes. It reduces the likelihood for systemic or procedural failure as a result of error.
In an article for The Doctor Weighs In, Paul Levy, a former CEO of a large Boston hospital, recently looked at the un-checked checklist, asking how many hospitals would publish reports about protocols not followed. By following checklists, clinicians can ensure they have done everything they could to keep the patient safe.
2. Checklists break down barriers to cultures of safety, further reducing the likelihood for error.
In a webinar with IHI Open School for Health Professionals in 2008, Dr. Pronovost shares his experiences with the first checklist he developed.
On the webinar, Dr. Pronovost candidly recalled that one of the biggest obstacles to implementing the checklist was not a lack of evidence for its recommendations but rather politics and breakdowns in teamwork. These traits are characteristic of a hospital environment that has not fully fostered the “culture of safety” advocated by the IOM in its 1999 report.
Disclosing a poor culture of safety as the cause for error is both difficult to do and beyond the scope of training for caregivers. Checklists can provide a lowest common denominator for caregivers from every discipline and can prevent politics from interfering with patient safety by giving everyone a common language for making decisions.
As Dr. Pronovost explains in the webinar, when the safety checklist was framed with the patient at the center, the politics disappeared. Checklists can therefore help to prevent errors that are caused by difficult-to-explain factors such as poor culture.
3. When errors do happen, checklists help communicate with patients and families how and why errors occurred, and what systems are in place to prevent failure in the future.
According to the AHRQ Patient Safety Network, components that matter most to patients include:
- Disclosure of all harmful errors
- An explanation as to why the error occurred
- How the error’s effects will be minimized
- Steps the physician (and organization) will take to prevent recurrences.
Checklists can be particularly useful for communicating the latter three components. By outlining the system in a short summary of recommendations, clinicians disclosing errors can pinpoint what went wrong, how the error’s impact can be minimized, and safeguards in place to prevent recurrences.
Checklists make it more straightforward to communicate errors with patients when they do happen.