Patient safety center steers clear of the blame game: New approach modeled after aviation industry

July 3, 2006

Indiana hospitals are drawing inspiration from the aviation industry for their latest push to reduce medical errors.

The Indiana Patient Safety Center, which opened July 1, will foster a blamefree approach to reporting errors, much like the environment promoted by the Federal Aviation Administration.

The result will be a culture that encourages system analysis to fix flaws that lead to an error, rather than one that merely heaps blame on the person who committed it, said Bob Morr, vice president of the Indiana Hospital and Health Association.

"The idea of the patient safety center is to accelerate change and improve learning at a much more rapid pace than we've been doing," said Morr, whose association spearheaded the new center's birth.

The center started operating with modest offerings, but hospitals and doctors already are hooked on its potential.

"This gives hospitals the opportunity to collaborate on their most important mission, that is the health and well-being of their patients," said Dan Evans, CEO of Clarian Health Partners, the largest hospital network in Indianapolis.

The new center may help rebuild some of the patient trust in health care that has eroded in recent years due partially to medicine's commercialization, said Tony Lennen, CEO of Shelbyville's Major Hospital.

"I think anything we can do as an industry to let the public know how unbelievably anal and worried we are about this patient safety stuff is a plus," he said.

Morr's association spent $500,000 in startup costs to create a set of tools and experts for its 167 hospitals, a total that includes nearly every location in the state.

It will start by surveying hospitals on their needs and helping them evaluate their own cultures for patient safety, Morr said.

The center, which is housed in the association's Indianapolis headquarters, eventually will delve into error analysis. Within a couple of years, it also plans to collect its own data on a broader topic, near misses or close calls, then use Indiana University and Purdue University researchers to help analyze it.

"The times that a clinical professional spots a potential error or a minor error that did not cause harm-that's what you need to gather and see if there's a common problem," Morr said. "If there's a common problem, there's got to be a way to improve it."

Medical professionals generally discuss errors and think about them during their peer-review process, said Dr. Kevin Burke, a Jeffersonville physician and president of the Indiana State Medical Association. But taking a look at what failed in the health care delivery system to cause the error is a unique approach.

It's also one his association embraces. "Physicians really have to depend upon a team of individuals to work toward patient safety," he said. Aside from surveys and research, the new center also will offer educational programs like one-day briefings and consulting with hospitals.

The new center's director, Betsy Lee, said its top potential benefit is to create a statewide environment that allows what one hospital learns to be "quickly adopted in other hospitals and by other physicians and providers."

Indiana's center is not unique. Its organizers used the Veterans Affairs National Center for Patient Safety in Ann Arbor, Mich., as a model. Maryland and Pennsylvania also are among a handful of states that have already developed these centers.

The Indiana Patient Safety Center also is one of several facilities to recently start initiatives geared toward reducing medical errors. Several hospital networks formed the Indianapolis Coalition for Patient Safety a few years ago. Clarian is developing a $44 million training center to help doctors, nurses and other medical professionals reduce errors. In January, the state Department of Health started requiring hospitals to report 27 types of severe problems shortly after they occur.
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