Talking about errors instead of hiding them goal of Vancouver hospital
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* Heather Kent

A profound change in the culture surrounding medical error that is shifting the emphasis from silence to safety is the goal of a new program at Vancouver's St. Paul's Hospital, the only Canadian centre participating in a collaborative project of the Boston-based Institute for Healthcare Improvement (IHI).

St. Paul's is now encouraging its staff to discuss errors and near misses, and it has set specific goals, such as reducing adverse drug events by 75%. The IHI estimates that 4% of hospitalized patients in the US suffer a “serious adverse event” and that up to 10% of patients experience an adverse drug event (ADE). The number of deaths resulting from these adverse events in American hospitals totals between 44 000 and 98 000 annually, says IHI; in comparison, about 45 000 Americans die every year in motor vehicle accidents. The goal of the IHI project is to improve safety in medication management by a factor of 10.

At St. Paul's, the number of adverse events is unknown. “There is no incentive to report anything,” says project coordinator Dr. Peter Dodek. “If people feel inclined to report an incident, they do.”

Dodek's first step was to survey staff about their attitudes toward reporting errors and how they think hospital managers will respond. The hospital is also developing corporate policies to encourage incident reporting.

“Far and away, most of the problems are system issues and not individual-blame issues,” explains Dodek, physician leader in the hospital's ICU. The project's challenge is to reassure staff that they won't be blamed. “We are going to thank you for reporting [the error],” he says, “because we want to know so that we can work on the issues that are responsible for it.”

Staff now talk about the issues behind the errors several times a week in the hospital's medical ward. During 5-minute “safety huddles,” nurses, doctors and pharmacists discuss any recent near misses or actual adverse events.

Every issue raised is listed on a tracking sheet, along with the names of the people who are resolving the problem; the sheets are posted in the nursing stations. Dodek says he's surprised by how simple some things have been to rectify. One problem involved a shortage of calculators needed to convert measurements for correct dosages. “Because no one has ever identified [these problems], we weren't aware of them.” 

Reconciling medications during different phases of a patient's care and reducing the number of ADEs are among the other goals of the project, which is being piloted in the ICU.

“Imagine this scenario,” says Dodek. “A patient is on a hypertension medication before [he] comes to the hospital, [he is] sent home with a slightly different drug and the patient takes both, thinking [he is] still supposed to be on the previous medication. The idea is to reconcile these lists so we minimize those kinds of errors.”

Dodek is delighted with the results. He says the open-ended questioning now being encouraged “has led to a huge list of things that we never would have known about because we never asked.”

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