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Ten years ago, the Institute of Medicine published To Err is Human [PDF], a groundbreaking report that pushed the issue of medical errors into the public spotlight. That we all make mistakes was certainly nothing new: Operational failures occur across all industries. But the impact of errors in the context of the health-care industry drew instant attention. Preventable medical errors resulting in injury cost the industry somewhere between $9 billion and $15 billion a year, the report stated. Even more shockingly, by some measures the number of patient deaths attributed to operational failures annually in the United States equaled the crash of one fully loaded 747 airplane every one-and-a-half days.
"At first, these campaigns are greatthey bolster the frequency with which solutions are shared by a significant margin....[But] at what point do people shut off?" Michael Toffel
Adler-Milstein. "In a sense, the units with high managerial engagement were already kicked into high gear," explains Toffel, noting that this result also suggests possible future research on the duration of campaigns. "At first, these campaigns are greatthey bolster the frequency with which solutions are shared by a significant margin. But there's a reason why we don't have a campaign all the time, whether it's in a hospital or for the United Way: fatigue. "A campaign's optimal duration for maximum benefits is still unclear. At what point do people shut off?"
should behavioral corrections be implemented? When should technological corrections be made? "I'm excited to look at this data longitudinally," says Singer. "Ideally, one would hope that an incident gets reported and that a solution is implemented so that the incident doesn't recur. We can look at whether this happens over time. Knowing this will make a significant contribution to improving patient safety, because a lot of hospitals rely on these reporting systems and promote their use, if only to fulfill accreditation requirements. "The real question remains, are they serving the intended purpose? It could be that very little happens with these reports in terms of the long-term learning that you would hope to see." Says Adler-Milstein, "We could also determine if the same type of incident is occurring in a given unit over time, even when it is being reported. That would then make it possible to focus on how particular units resolve their problems." Identifying pockets of excellence would
enable more qualitative research to determine what exactly a unit is doing to achieve its successand to identify how those practices could be codified and adopted elsewhere. "Health care started out with largely independent practitioners and a limited body of knowledge," says Adler-Milstein. "Given the changes that have occurred recently, technological and otherwise, health care hasn't caught up quickly enough with the new practice methods that accompany this very different, modern-day model. I hope we will get there eventually, but right now there is a lag." Drilling down to discover when frontline employees speak up most constructively, and how to translate this into problem solving, should help bridge that gap.