A recent interview with OR Excellence speaker Kenneth P. Rothfield, MD, MBA, CPE and CPPS talks about how patient safety has not improved in the last 54 years, despite the many medical advancements made. According to a study we mentioned in a previous blog, more than 400,000 people die each year in the U.S. due to preventable medical errors, making it the third leading cause of death.
One of the first things Rothfield addresses is the fact that medical communities try to create systems aiming to completely eliminate human error, when there is in fact no way to human-proof a system in the health care industry. We rely on doctors, but they are human and may unintentionally make errors by bypassing policies, engaging in risky behavior or not paying enough attention.
Rothfield goes on to say the solutions to these problems are more cultural and social than they are technical. For example, a recent trend in attempts to reduce the amount of medical errors included checklists. However, this did not solve the problem or change the number of incidents because implementing the checklists were a function of culture and leadership. The solution to medical errors, according to Rothfield, would involve changing the way people feel about the work and how people interact.
What Kind of Changes Must Be Made in the Health Care Industry to Reduce the Number of Medical Errors?
One example of a cultural and social change that would help solve the issue would be to put doctors in a model where they are not strictly autonomous. Meaning, doctors would have to understand they are part of a team and each member of that team has just as important of a job as the doctors themselves. Or, as Rothfield puts it, “the person taking out the trash is just as important as the person taking out the gallbladder.”
Doctors must understand how to help the team rally for a common cause, that being patient safety, rather than trying to compel staff to do things simply with authority. Though to be fair, doctors are trained from day one to understand hierarchy, autonomy and competition, so it would be a huge culture change to teach them to work as a member of a team. However, this is the change we need to make.
While there is some emphasis on teaching leadership skills in medical schools, it is certainly not the defining feature in what doctors are meant to learn in their medical education. That said, Rothfield believes that until doctors are taught from the beginning how to communicate with patients and understand their roles as leaders, there will be little progress in the way of fixing medical errors in the future. Rothfield believes the tipping point that motivates health care professionals to reduce the number of medical errors will happen when patient outcomes determine how they get paid.