Engineering Errors Out of Health Care

In my first month as a new communications associate with the Foundation’s Pioneer team, one of the many glaring items on my task list has been to gain a solid working understanding of the power of disruptive innovation and what it takes to achieve it. While this may take a while, thankfully Susan Promislo has given me a stack of project briefs and proposals that illustrate different aspects of this equation in a pretty straightforward way.

 

In one intriguing new effort, a team led by Peter Pronovost– professor of anesthesiology and critical care medicine at Johns Hopkins and renowned patient safety expert – is looking to a collaborative model that has yielded huge improvements in commercial aviation safety, and testing whether the application of a similar method could do the same for hospital patients.

Hospitals have engaged in noteworthy work to improve quality and safety, but other approaches are needed to accelerate improvement. Pronovost’s project is honing in on a public/private partnership model that has been highly successful in preventing aviation deaths and disasters.

 

Between 1995 and 2003, 2,261 people died in “controlled flight into terrain” (CFIT) plane crashes. Based on recommendations from the White House and Congress, the formation of Commercial Aviation Safety Teams (CAST) has drawn on the knowledge of key leaders from all sides of aviation – major manufacturers and airlines to the FAA and DOD. One of CAST’s first major recommendations led to the commercial adoption of a “terrain awareness and warning system” for all airplanes registered in the United States, and an altitude warning system for ground radar. In 2004 there were no CFIT airplane crashes, and all such accidents since then have involved planes without the warning system. 

 

The CAST model – in essence a targeted convening at which a bunch of really smart and influential people from key stakeholder groups have at the problem – has provided the aviation industry a vehicle to identify and prioritize major safety hazards and design and implement strong systemic fixes. They have essentially engineered the problem out of air flight to the greatest extent possible.

 

Pronovost has similar goals in mind for health care through the Public Private Partnership to Promote Patient Safety (P5S), whose charge is to identify and select a single patient safety hazard and test methods to dramatically reduce it in hospitals across the country. Stakeholders representing the Agency for Health Care Research and Quality, U.S. Pharmacopeia, Joint Commission, FDA and chief medical offices of large health systems have expressed interest in joining this effort.

 

One safety area that appears ripe for this kind of intervention is the use of hospital defibrillators. As Pronovost and other co-authors point out in a recent Health Affairs article, “Under time pressures, and often with limited hands-on experience, doctors often fumble to set defibrillators accurately. What is needed is a yoke-type solution that redesigns the defibrillator controls to be intuitive to eliminate the potential for mistakes… However, device redesign requires a coordinated effort among manufacturers, clinicians, human-factors engineers, and regulators.”

 

The hope is that P5S can create a vehicle for such high-return and breakthrough thinking that doesn’t now exist in health care. In a recent Health Affairs blog post, Pronovost discussed this project along with some obstacles P5S is likely to face – such as the “myth of perfection” among doctors.

photo by Allen Rockwell from Flickr