Healthcare organizations that have been able to break down medicine’s hierarchical culture and its punitive approach to errors have made great strides in improving patient safety, according to the study “Stories from the Sharp End: Case Studies in Safety Improvement” published in the March issue of the Milbank Quarterly. The researchers explore the strategies employed by five hospitals and by Kaiser Permanente of California to encourage staff to report errors and near-misses and voice safety concerns. Among the results: Johns Hopkins saved $2 million annually from reduced ICU lengths of stay and prevented eight deaths; Missouri Baptist Medical Center in St. Louis decreased emergency calls for respiratory arrest by 60% and decreased cardiac arrests by 15%; OSF St. Joseph Medical Center in Bloomington, Ill., reported a 91% drop in adverse drug events, and Sentara Norfolk General Hospital reported an 84% reduction in ventilator-associated pneumonia. The authors recommend that purchasers use pay-for-performance incentives to motivate providers to meet safety goals, regulators use state databases to alert providers to safety threats and improvement possibilities, and educators begin changing medical culture by instilling new attitudes about communication, teamwork, and human fallibility.
