Description

This health video looks into hospital safety and how to improve it, part 2/3.

Transcript

Jennifer Matthews: First do no harm, important words in the medical world, but sometimes harm is done. Dr. Jim Bagian: We often say experience is the best teacher. It's also the most costly. Who pays the tuition for our education? The patient. Jennifer Matthews: Dr. Jim Bagian, a former astronaut, is Head of the Veterans Affairs National Center for Patient Safety. The center tracks medical errors and close calls. Dr. Jim Bagian: And since close calls happen anywhere from 20 to 600 times more commonly than the actual event that could occur, that gives you all those times to learn the easy way. Jennifer Matthews: What gets people to report every mistake, including near misses? The VA's blame-free culture. Dr. Jim Bagian: I call fault the "F" word of medicine. Instead of saying whose fault is it, it's about saying, What happened? Why did it happen, and what do we do to prevent it? Jennifer Matthews: The VA center in Topeka led the way in prevention efforts. Here, nurse Sue Kinnick dreamt up the idea of bar-coding medications after watching a rental car company do business. Russell Carlson: She thought, well you know, if they can track cars across the nation, then why can't we track one pill in a hospital. Jennifer Matthews: Sue died of cancer in 1997, but her bar-coding innovation has changed the way the VA operates. Patients check in, receive a bar-coded wristband, and their meds are entered into a computer. Before a drug is given, both are scanned. A mis-match prompts an alert. Since 1993, the VA has seen an 80% decrease in medication errors. Russell Carlson: The prototype with over 8 million doses dispensed had created or prevented over 549,000 medication errors. The last words out of Sue's mouth is that she was going to heaven to start bar-coding the angels. Jennifer Matthews: The VA isn't the lone star in patient safety. Last year, the American Hospital Association gave its first ever Quest For Quality Prize to Missouri Baptist Medical Center in St. Louis. What did they do to earn it? Dr. Max Cohen: The first thing that we realized was that we had to was change the whole culture of the organization. Jennifer Matthews: Dr. Max Cohen says the next most important step was hiring Nancy Kimmel as the patient safety specialist. Nancy Kimmel: I think patient safety 24/7. Jennifer Matthews: Their patient safety hotline is used to report safety concerns or close calls right away. Then, a newsletter announces what actions have been taken. Another program works on physician handwriting to avoid prescription errors. Patients also carry a card listing all their current prescriptions. Nancy Kimmel: A lot of the facilities need to take the initiative to start working on patient safety and not wait for some legislator to tell you, you need to do it. Jennifer Matthews: Dr. Cohen says they've only spent about $100,000, and it's working. Harm caused to patients as a result of errors has dropped 75%. Dr. Max Cohen: We have a long way to go yet before we can truly claim, which we want to claim, that we are the safest hospital in the United States. Jennifer Matthews: This is Jennifer Matthews reporting.