Hospital administrators at Northbay Medical Center in Fairfield, California, have implemented a program called TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety. The program, developed by the Department of Defense based on military and private aviation, is intended to improve communication among staff members to prevent medical errors.
"Anyone along the line can—and has a responsibility to—let the team know if care is problematic," says hospital spokeswoman Joanie Erickson. Workers at the hospital can also report problems anonymously.
The Agency for Healthcare Research and Quality, part of the U.S. Department of Health, published a report in May on how hospitals use process and design to error-proof the care they give. The report made one thing clear: The culture of medicine is such that doctors and hospitals believe the way to eliminate errors is for clinicians to improve their practices.
"This simplistic approach not only fails to address the important and complex system factors that contribute to the occurrence of adverse events but also perpetuates a myth of infallibility that is a disservice to clinicians and their patients," states the report, which adds that inadequate staffing levels make process improvement difficult.
"Anyone along the line can—and has a responsibility to—let the team know if care is problematic."
Northbay Medical Center spokeswoman
With this in mind, Virginia Mason Medical Center in Seattle took a systematic approach toward reducing human errors and turned to auto industry leader Toyota.
Dr. Robert Mecklenburg, chief of medicine at Virginia Mason and now director of the hospital’s Center for Health Care Solutions, which was established in September, referred to Toyota during the 2006 World Health Care Conference as "everything we weren’t and everything we desired to be."
Specifically, the auto manufacturer was customer-focused, defect-free, low-cost and driven by innovation for quality improvement. Hospital executives spent two weeks on a Toyota assembly line learning how to avoid mistakes.
"This was so impressive to folks at Virginia Mason that we decided all the executives would get certified to teach the Toyota production system," Mecklenburg says.
The hospital standardized hundreds of processes, including mistake-proofing hoses and tubes so wrong medicines could not be administered through them.
Like at many hospitals, it took a tragedy to change practices prone to error.
On November 23, 2004, Mary McClinton, a patient at Virginia Mason, died after she was mistakenly given the antiseptic chlorhexidine. In a memo written by Mecklenburg, the hospital acknowledged the mistake was preventable.
"Many were aware of the hazard in the system that could lead to injection of the wrong solution and aware of a simple method to prevent this occurrence," the memo said. "No one took action to change the process before this tragedy occurred."
Workforce Management, November 19, 2007, p. 19 -- Subscribe Now!