TAMPA, FL – Greater collaboration among healthcare professionals could prevent some of the tens of thousands of patient deaths and injuries that occur in hospitals and clinics each year, according to a recent exercise organized by consulting firm Booz Allen Hamilton.
The exercise, which Booz Hamilton also bills as a "wargame," was conducted last week for the American Board of Quality Assurance and Utilization Review Physicians, Inc., in New Port Richey, Fla.
It was the second simulation in six months aimed at showing all stakeholders in a patient's care that their collaboration, communication and planning are key to preventing medical errors.
And, when a medical error does occur, said Booz Allen Hamilton Vice President Susan Penfield, the exercise shows that collaboration again helps the team recover from the error more quickly.
Moving quickly to take responsibility for an error and figure out what went wrong, using the team approach, as opposed to trying to assign blame, is likely to prevent the same error from occurring again, said Penfield. That means other injuries could be prevented or lives could be saved.
Unfortunately, many institutions take what Penfield calls a "CYA," approach to errors, one in which the people involved are discouraged from taking responsibility. And, she adds, once the lawyers are called in, the openness required to analyze what went wrong goes out the window.
Several participants said the simulation was extremely valuable with practical lessons learned.
"I really think the two cases pointed out how important systems are, and communications between systems, in order to prevent adverse reactions from occurring," said Arthur Broder, MD, chairman of the American Board of Quality Assurance and Utilization Review Physicians Inc. "These strategic simulations allow you to look at the issue from a multidisciplinary approach, vital to preventing medicinal errors and surgical and physical adverse events."
"During the course of the exercise, the participants recognized that the immediate post-event formation of multidisciplinary teams to address and understand medical errors improves the ability of providers to respond and react to issues and fallout," Penfield said. "Although such behavior is understood as necessary, it was the first time the wargame participants had worked toward immediately responding to a medical error in a multidisciplinary team."
These findings point out that communications with each other, and even with patient families, is often overlooked in exchange for expediency, she said.
Some of the key findings:
– Separate disciplines within hospitals or clinics, such as doctors, administrators and nurses, have a tendency to try solving problems within their own groups, rather than reaching out to the other disciplines to get a broader picture.
– Healthcare professionals may tend to find ways to work around safety processes that are cumbersome, indicating to some that the processes in place may not be working or are in need of updates and improvements.
– Staffing shortages were placing incredible burdens on entire hospital infrastructures.
The goal of the patient safety wargame was to allow participants to experience and deal with catastrophic errors in a safe environment, so that alternative strategies can be addressed, Booz Allen Principal Mark Frost, a gaming expert, said. "Hopefully these lessons will be carried to hospitals throughout the United States and beyond."
Booz Allen develops strategic simulations and wargames for federal and commercial clients.
