Articles, PSQH January 22, 2011

Failure is Not an Option

by Barry P Chaiken, MD

Healthcare could learn much from Gene Kranz. A recipient of the Presidential Medal of Freedom along with other mission scientists and crew, Kranz led his Tiger Team of experts at NASA in its successful effort to bring three astronauts on a perilous 500,000 mile journey around the moon and back home to Earth. Apollo XIII, launched in April 1970 to be America’s third manned moon landing, suffered a catastrophic explosion of its service module on the way to moon, leaving the command module without adequate power to run the spacecraft’s instruments or life support. Kranz’s lead White team, aided by three other teams of experts, inventoried the available resources and improvised all along the way to bring the three astronauts, James A. Lovell, Ken Mattingly, and Fred W. Haise, back safely. Although inaccurately attributed to Kranz, “Failure is not an option” is now associated with the unwavering commitment by the teams of scientists to find a solution to a seemingly unsolvable problem.

This past December marked the 11th anniversary of the release of the landmark Institute of Medicine study, To Err Is Human, attributing upwards of 100,000 deaths and more than 1 million injuries to medical errors caused by systematic failures of our healthcare delivery system. In response to the 1999 report, accreditation bodies, payors, providers, hospitals, and government agencies launched numerous efforts to reduce the number of medical errors, and in turn the morbidity, mortality, and wasted resourses associated with them.

Despite this great effort and investment, failure sadly remains a common occurrence in our healthcare system. According to a November 2010 article in The New England Journal of Medicine, medical errors continue to be a dangerous, common occurrence, appearing just as frequently today as they did more than a decade ago (Landrigan et al., 2010).

The authors offered cautious advice to their readers:

“…achieving transformational improvements in the safety of health care will require further study of which patient-safety efforts are truly effective across settings and a refocusing of resources, regulation, and improvement initiatives to successfully implement proven interventions.”

Although the incentives provided by the federal government through the “meaningful use” initiative foster the utilization of health information technology to improve quality and reduce errors, the use of health information technology alone will not reduce medical errors.

The meaningful use criteria evolved to encourage utilization of health information technology in a beneficial way, but it remains unclear what the true impact of the initiative will be on safety and costs. At this juncture, it is reasonable to assume those results will be mixed.

First steps begin with identifying well-defined goals and objectives (e.g., elimination of IV medication dose errors in the pediatric intensive care unit). Achieving these outcomes requires the use of proven, documented workflows built from effective processes, some of which employ health information technology tools. In addition, these tools collect data useful in monitoring the effectiveness of the workflow and identifying possible improvements to enhance results.

Effective use of information technology to reduce medical errors requires identifying the cause of the medical errors and the clinical transformation—the change in how we clinically do something—that reduces the probability of the error occurring. Transformative solutions that reduce reliance on perfectly executed human actions while shifting that burden to tireless health information technology are much more likely to consistently reduce errors than those that fail to leverage such technology.

Only through intelligent, purposeful implementation of healthcare information technology will we be able to reduce medical errors. Using healthcare information technology in a shotgun mode fails to guarantee any level of success. And failure is not an option.

Excerpts from: Failure Is Not An Option. PSQH, January/February, 2011


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