Patient Safety Innovations that Could Dramatically Cut Medical Error

After the 1999 release of To Err Is Human, the landmark Institute of Medicine report that revealed that hundreds of thousands die each year from medical errors, the problem of patient safety was elevated to the level of an epidemic. The wake of increased public awareness about patient safety has led to thousands of initiatives across various health care systems attempting to heal not only patients but systems themselves.  The good news?  High-quality data has shown that patient safety initiatives are effective in reducing preventable adverse events.  But with a recent CDC report revealing that medical error causes over 250,000 deaths annually – making it the third leading cause of death in the US – we face an urgent need to create disruptive innovation to finally make hospitals safe for patients.

Hats off to the following patient safety innovations that could help achieve this aim.

The Digital Time-Out

The surgical “time out,” formally defined in a 2008 WHO report, has become the standard of care for preventing wrong site, wrong procedure, and wrong patient surgeries.  But critics of the time out process cite inattention and lack of team engagement as common pitfalls that limit the pre-incision procedure’s efficacy.  Enter the timeout of the future: a video-based checklist process that streams all important patient data and surgical details on a monitor in the operating room.  Its implementation in a community hospital in Texas led to significant increases in attentiveness and team communication, as well as a higher likelihood of discussing critical operative needs and patient concerns.

Pop-Up Photos in Reducing Medication Errors

Wrong-patient medical errors, though rare, are among the most dreaded medication administration mistakes because of their potentially catastrophic consequences.  To ensure that the correct drug goes to the right patient – and only that patient – doctors at Children’s Hospital Colorado must now confirm orders entered into their computerized system through a pop-up verification screen that includes a large photograph of the patient.  After its implementation in 2010, the number of annual wrong-patient medication errors dropped by 75%.

Computer Simulation

Simulation training for surgical procedures has become a mainstream educational method that is known to enhance knowledge and skill among doctors-in-training.  More recent data has established a direct connection between procedural simulation and patient safety outcomes.  One study, for instance, found that central-line associated blood stream infections (CLABSIs) fell by 85% after internal medicine residents completed computer-simulated procedure training.  A study among surgical residents found that those who completed digital simulator training on totally extraperitoneal (TEP) inguinal hernia repair were able to perform the procedure faster and better than traditionally-trained residents – and with lower complication rates.

Keeping Hands Clean with Novel Visualization Techniques

Ever since the Joint Commission identified handwashing failures as the cause of nearly 100,000 American deaths each year, hand hygiene has been a hot-spot in patient safety.  To combat a sub-optimal handwashing compliance rate, Henry Ford Hospital used what they dubbed “the yuck factor.”  Workers on hospital units were shown magnified images of bacteria found on common things like a mouse pad or desktop.  Two months later, handwashing rates had increased by nearly 25%.

Telemedicine to Cut Preventable Admissions

Although often overlooked, one of the best ways to decrease preventable hospital errors is to decrease preventable hospital admissions.  Telemedicine offers an unprecedented opportunity for doctors to remotely address patient concerns that may otherwise bring them to the hospital.  A study among senior living communities showed that in communities where residents were highly engaged with telemedicine, visits to the emergency room dropped by 28%.  Empowering patients to care for themselves at home could be a landmark win for the patient safety movement.

By Nicole Van Groningen

@Nvangroningenmd