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New Patient Safety Effort Uses Aviation Industry Model



April 13th, 2009

A public-private alliance known as the Commercial Aviation Safety Team (CAST) has greatly improved aviation safety. A similar alliance among health care stakeholders could reduce medication and device errors and wrong-site surgeries, renowned patient safety expert Peter Pronovost and coauthors say in an article published April 7 on the Health Affairs Web site. Pronovost is a professor in the Department of Anesthesiology and Critical Care Medicine at the Johns Hopkins University in Baltimore.

Pronovost is working with a large range of public and private groups to establish a health care counterpart to CAST, dubbed the Public Private Partnership to Promote Patient Safety, or P5S. Those involved include the Agency for Healthcare Research and Quality, the Food and Drug Administration, the Joint Commission, and many of the largest health systems in the country. Under a planning grant from the Robert Wood Johnson Foundation, Pronovost and his colleagues are refining plans for the governance, processes, and finances of P5S for presentation to stakeholders this summer.

Pronovost says P5S is designed to change the way that hospitals attempt to deal with patient safety issues. One example he and his coauthors cite in their article is the frequent mistakes physicians make when they use defibrillators to shock the hearts of patients in cardiac arrest. The usual approach to problems like this is for hospitals to reeducate their staff, to essentially tell physicians “to be more careful,” Pronovost tells the Health Affairs Blog. (The Wall Street Journal Health Blog’s discussion of Pronovost’s article is here.) 

Unfortunately, this approach is both extremely expensive and extremely ineffective, Pronovost points out. A better approach would be to redesign defibrillators with features such as automated default settings to make errors impossible. But this sort of “strong” intervention requires coordinated effort among clinicians, manufacturers, regulators, and human-factors engineers; P5S is designed to provide a forum for this type of collaboration.

By including the country’s largest health systems, P5S is also designed to create the necessary market clout to drive manufacturers to emphasize safety in their designs. Neither Johns Hopkins nor any single institution can force market change, Pronovost says. Indeed, even colleagues from the United Kingdom and Canada have been told that their national health systems are not big enough to drive change in a worldwide market, he notes. But by bringing together “an enormous percentage” of the hospital beds in the United States, P5S will be in a position to tell device manufacturers that “we’re willing to buy your new technology, and we may even be willing to pay more for it,” but we want it to enhance patient safety.

Government agencies such as the FDA and the Centers for Medicare and Medicaid Services are involved in the push to create P5S, and Pronovost is open to using government regulations to promote safety when that seems the wisest course. “We need to pull as many levers as possible,” he says. However, Pronovost is optimistic that the market will respond to a demand for safe devices. Up to now, there hasn’t been a robust mechanism for manufacturers to hear about device shortcomings, he explains: “They hear one doc say ‘design it this way’ but they don’t know if that is wise or just one doc.”

Pronovost says that device manufacturers are seeking to participate in P5S, but he is holding off involving them until the alliance works out its governance and conflict of interest policies. “Managing conflicts of interest is essential to this process, because the work has to be informed by good science, not who is partnered with which device manufacturer,” he says.

The “Myth Of Perfection”

One of the biggest barriers to implementing strong safety interventions is the “myth of perfection” among physicians, Pronovost says: “Physicians must perform perfectly, and when they don’t there is shame and guilt and denial.” He suggests that his own specialty, anesthesiology, may have become a leader in implementing strong safety interventions partly because anesthesiologists are “the only physicians that work for, or perhaps with, another physician” — the surgeon. Thus, anesthesiologists “may approach health care a little more humbly.” As an anesthesiologist, Pronovost states, he recognizes that “fallibility is part of the human condition, that I am going to stick the tube in the wrong place sometimes and therefore I need to design out the ability to make that mistake.”

The perfection myth, while still strong, is waning in the face of repeated harmful events, Pronovost says, and he suggests that policymakers seem ready for action. Pronovost recently testified in front of the Senate Health Education, Labor, and Pensions Committee, and he paraphrases a question he received from Sen. Kay Hagan (D-NC): “Let me get this straight – you mean to tell me I can not put a diesel fuel pump in my gas car because they don’t fit together, but I can go into a hospital and have an epidural connected to my IV?” Hagan’s HELP colleagues shared her incredulity that there wasn’t a mechanism for preventing this, and they unanimously agreed on the need for one, according to Pronovost.

In 2005, Congress created patient safety organizations (PSOs), overseen by AHRQ, to receive medical-error reports. Pronovost praises PSOs as “the first step toward a national error reporting system,” but in the 2005 legislation there was “no real discussion about what we were going to do with all these error reports.” P5S is designed to fill this vacuum, Pronovost says.

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2 Trackbacks for “New Patient Safety Effort Uses Aviation Industry Model”

  1. | Thomas A. Sharon, R.N., M.P.H.
    May 24th, 2009 at 6:51 pm
  2. robust
    April 13th, 2009 at 11:02 am

2 Responses to “New Patient Safety Effort Uses Aviation Industry Model”

  1. Keisha Sheppard Says:

    Health care personnell are to deliver safe patient care. The aviation industry has the process checks incorportated into the daily operations. It is apparent that health care can learn from the process check methods that reduces substantially negative outcomes to people. Health care facilities can benefit from a group such as the Public Private Partnership to Promote Patient Safety (P5S) in which medical errors that occur daily that result in death can be avoided.

  2. sjdavidson Says:

    I love it–design out failure. Anesthesiologists were leaders in this and brought the medical device designers and manufacturers along.

    What’s not covered is the majority of practice where it’s process design, not device design that underlies the failures. Still in the world with tort law overhang, the transition, nee transformation, remains challenging.

    Pronovost is not alone, yet many colleagues seem resolute–perhaps out of fear of medmal liability–that aspects other than process design must change first.

    Deming taught me to start the pilot small with certainty of success; Pronovost has done that. How do the rest of us help propagate the vision–the resistance I experience is enormous.

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