Chapter 29: PATIENT SAFETY AND QUALITY IMPROVEMENT

Like medical ethics, patient safety and quality improvement are complex topics, but with a few basic principles you can master them for the purposes of the exam. Here are the main areas to focus on:

• Emphasis on the system, not the individual
• Team approach
• Culture of transparency
• Non-punitive approach
• Learning from errors

SYSTEMS APPROACH

The best way to prevent medical errors and improve quality is to look at the systems involved in delivering care. That includes the people, policies, practices, information, informal culture, and everything else that goes into making medical decisions and putting them into practice. The systems approach clearly recognizes that people and technology are fallible and takes that into account. It analyzes what makes the errors more likely (e.g., fatigue, time pressure, incomplete information, lack of maintenance, etc.) and tries to reduce those causes.

It also looks for ways to prevent human or technological errors from actually causing harm. Identification of risks within a system due to possible human errors is the first step in developing strategies to lower or eliminate the risk of these errors from occurring. For example, given that there is always a chance that the doctor will order the wrong vaccine, what can be done to prevent that error from being carried through? Pop-up alerts from the electronic medical record, double checking by medical assistants, and integration with a state-wide immunization registry are examples of measures to correct an error before it causes a problem.

This contrasts with an approach that focuses on the individual only. While it’s true that human error is often the immediate cause of an adverse event, it is unrealistic to think that we can eliminate adverse events by only focusing on the reduction of errors made by individuals.

The bottom line for your exam is that you should select answer choices look at how to improve the whole system rather than answer choices focused on the blame of an individual or the expectation that an individual should be more reliable in the future.

TEAM APPROACH

High quality and safe care require well-functioning teams within the overall healthcare system, not just competent physicians. Leadership, communication skills, and team building are all important. The team leader should take the primary responsibility for the functioning of the whole team. Depending on the situation, a team could include the doctor, other providers, assistants, therapists, lab, pharmacist, social worker, front desk, or more.

Regardless of the chain of command, part of the team approach is the idea that everyone is responsible for safety. The physician (and system) should welcome safety warnings from nurses, the housekeeping staff, and even the valets. So choose an exam answer that features that kind of openness.

CULTURE OF TRANSPARENCY

A culture of transparency means that incidents and errors are freely acknowledged. In fact, the team actively seeks out evidence of errors in order to learn how to correct them and prevent them in the future. In medical ethics, truthfulness is a core value, and in the context of patient safety and quality improvement, there is emphasis on the internal process of acknowledging errors. We improve quality and make care safer not by hiding mistakes or blaming individuals, but by finding as many errors and near-misses as possible, analyzing them, and creating systems-based solutions to prevent them in the future.

For the exam, choose answers that involve a positive approach towards recognizing, communicating, and documenting incidents and errors. Do not ignore them, place blame on individuals, or deny their existence.