Cheryl Clark (@CherClarHealth) is AHCJ's core topic leader for patient safety, a MedPage Today contributor and inewsource.org investigative journalist. For most of 27 years, she covered medicine and science for the San Diego Union-Tribune. After taking a buyout in 2008, she became senior quality editor for HealthLeaders Media.
Today, Sept. 17, is the first World Patient Safety Day, declared by the World Health Organization to draw attention to ever-present need – still – to reduce avoidable patient harm in health care settings.
And November marks the 20th anniversary of “To Err is Human,” the National Academy of Medicine’s 1999 report that estimated as many as 98,000 people die a year in United States hospitals. That widely publicized report called for a national agenda to improve patient care processes to make it easier for honest providers to safely treat patients and harder for them to cause harm. Continue reading →
“At the moment, we kind of say, ‘Well, we do it this way.’ Everybody thinks they know really what happens, but not everyone does,” (lead author Ken Catchpole, PhD) said. “There is lots of individual variation that creeps into these things. Sometimes that’s good, and it’s responsive to individual patients. But often that creates these uncertainties that increase the opportunities for errors to happen.”
Catchpole has helped physicians at London’s Great Ormond Street Hospital for Children use F1 techniques to improve their handoff of pediatric heart surgery patients to intensive care, with results first published in the May 2007 issue of Pediatric Anesthesia. New protocols developed in response to video examination of pit stops and visits with F1 racing crews helped cut the duration of patient handoffs and reduced omissions of critical information and technical errors by 67%, the study showed.
Here’s their arithmetic, courtesy of The Boston Globe‘s Elizabeth Cooney
Time was the biggest cost in setting up the checklist, Gawande and his co-authors write in the journal Health Affairs. They estimated that a hospital with at least a 3 percent rate of complications per year would begin to see savings after five major complications were prevented. That means a hospital where 4,000 noncardiac operations were done each year could save about $25 on each procedure, or about $100,000 annually, they concluded.