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Dr. Perlin on Medical Errors

One of the medical organizations that has invested the most in technology aimed at reducing medical errors is the Veterans Administration. The following is an extended transcript of Dr. Jonathan Perlin, undersecretary for health affairs at the Department of Veterans Affairs, discussing the effort with Susan Dentzer.

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  • SUSAN DENTZER:

    Why did the VA decide that it was going to tackle the patient safety issues, head on?

  • DR. JONATHAN PERLIN:

    Well, I think it's fair to say that historically, the VA's reputation was not, was not perfect, and we realized that we needed to change, and perhaps we were more motivated than anyone else to take a good hard look at ourselves and reframe how we provide care, and what we saw was that we needed to improve safety, improve quality, and improve the compassion with, with which we deliver care.

    And so we actually invented new programs. Our National Center for Patient Safety actually preceded the Institute of Medicine, report by a full year, and allowed us to focus squarely on diminishing harm to patients, reducing injuries that, that occur unintentionally but as a result of health care.

  • SUSAN DENTZER:

    And I don't want to put too fine a point on this but you said the reputation of VA was not perfect, it was — well, reputationally, anyway, it was well below perfect. There were a lot of errors, there were a lot of — it was perceived that there were a lot of incompetent physicians practicing within the system and incompetent care being delivered. Is that fair?

  • DR. PERLIN:

    I think the perception of VA was very tarnished in the early '90s, and so we really were motivated by nothing less than survival in meeting our mission of caring for veterans, which is really — we're a very mission-driven organization. But survival was also very compelling and that made the status quo extremely uncomfortable and compelled us to change, to build systems, to develop safety as part of how we do business, and in fact you might ask what, what is our safety plan? What is our quality plan?

    We don't have a safety plan and a quality plan. It's our business plan. We deliver safe, effective, compassionate care. We have met our business goals and that is our, our safety/quality plan.

  • SUSAN DENTZER:

    So again to stick with a bit of the history, you said the patient safety center was established in 1997, that would have been.

  • DR. PERLIN:

    That's right.

  • SUSAN DENTZER:

    What was tackled first? How was it approached?

  • DR. PERLIN:

    I think one of the most important things in terms of approaching improvement to safety was awareness that there were problems with the way, not just VA, but the way we all deliver health care. Professionalism is important but it's inadequate. You actually had to learn how harm occurs to patients.

    So we developed a very elaborate confidential reporting system, so people could identify those incidents where things went wrong, not unique to VA, but things go wrong, unfortunately, as the Institute of Medicine report shows, all too often in health care.

    So we had to be aware, not only of the extremely catastrophic issues, but more importantly, or at least as importantly, a number of those lapses where things could have had catastrophic consequences.

    By learning about those, by acquiring the knowledge about each of those, then you could build systems that recognize that humans are fallible and to help to mitigate the risk that's a part of health care and help to, to keep us safe and assuring that care is delivered effectively.

    Let me give you an example. It's well-known that hospital is often complicated by medication errors, and many times, worse yet, these are avoidable.

    We have throughout VA, now, nearly a 100 percent electronic order entry by the prescribing, usually physician. And what's so important about that? It presents to the physician the drug, shows if the patient has any allergies or has a reaction to the drug previously, so prevents a mistake from happening, prevents harm to the patient. Also provides the best medication, and even at the point of administration where drug A might go to patient B, and lead to a significant problem, we have bar-coded medication administration throughout the system, where the nurse scans the bar code on the medication, scans the bar code on the patient's wrist band, assuring that it's the right medication, in the right dose, for the right patient, at the right time, administered by exactly the right person and virtually eliminating errors at that point of administration.

  • SUSAN DENTZER:

    And you said it's almost a 100 percent penetration within the VA system… What's the comparable rate in the broader U.S. health care system?

  • DR. PERLIN:

    Throughout VA, we have computerized provider order entry about 94 percent of the time. Across the country, the rate is only about 8 percent. Computerized provider order entry is so critical in terms of assuring that there is no transcription error, no error in, in terms of ordering something which — it's already known the patient has an allergy, and assuring the best medication goes to the right patient.

  • SUSAN DENTZER:

    And what has been the commensurate reduction in adverse drug events within the VA system as a consequence of this?

  • DR. PERLIN:

    well, you know, it's difficult to measure what doesn't occur, but we know from Dave Bates and Lucien Leape's work, that the rate of hospital errors with medications is about one in six-and-a-half admissions.

  • SUSAN DENTZER:

    So how much have you seen by way of errors reduction related to adverse drug events as a consequence of this?

  • DR. PERLIN:

    It's difficult to measure what doesn't happen but what we know is that perhaps across the country, one in six-and-a-half hospitalizations is complicated by an adverse drug event. With the bar-coded medication administration we've virtually eliminated errors at the point of administration to the patient.

    With the provider order entry, we've reduced the errors at the point of, of ordering, errors due to transcription, illegible handwriting, even making bad choices where the patient has a known allergy, eliminated that, and the middle part, we have a lot of robotics, and so to each that — each step of the process, the process of ordering, the process of dispensing, using robotics, and the process of administration, using bar coding, we've taken errors out of the system and can say at the bar coding level, there are virtually no errors that occur at that point.

  • SUSAN DENTZER:

    So does that mean instead of one out of every six and a half, at the VA it's zero?

  • DR. PERLIN:

    I am aware that, of one or two errors that occurred when something has been mislabeled. So I can't tell you it's zero but I can tell you it's a long, long way from one out of every six and a half patients.

  • SUSAN DENTZER:

    And what — I assume that the impact on mortality, or to turn it around, the survivability of a hospital stay now at the VA has gone up commensurately. Do you have a way of capturing that in data?

  • DR. PERLIN:

    We, we use Health Services Research to try to estimate what the effects of some of these things are, and, you know, if you look at a drug which is known to be life-saving, such as beta blockers, which reduce your chance of dying after a heart attack, the national rate for getting a beta blocker after a heart attack still remains at about 50 percent, despite the fact that its benefit is known, been known for almost two decades.

    In VA, almost a 100 percent, 99 percent of our patients get a beta blocker after their heart attack, reliably. You might ask what about the last one percent. We may have some, some noise in our data collection, that we can't account for that, but we measure and we hold ourselves accountable for those measurements, and of course the patient is the one who benefits.

  • SUSAN DENTZER:

    Let's take a moment here to put the patient safety issue in the context of the broader quality of health care issue. How do you see that here at the VA?

  • DR. PERLIN:

    It's a, a tremendously important point to put safety in the broader context of, of quality, because sometimes there's no great line in the sand differentiating between safety and, and quality.

    Safety is very foundational… If you go to a hospital for surgery, you need to make sure that the surgeon washes his or her hands to be safe from infection. But that's pretty foundational. You really went for the operation because you needed effective therapy. And so part two has to be quality, effectiveness in the technical delivery of the service. But you'd be — you could receive care that's safe and technically effective and still be very dissatisfied. It has to be delivered in a way that's really patient-centered, a way that is humane and compassionate, and meets your needs.

    So our goal in VA is to make sure that we build in safety and quality or effectiveness as system properties in a broader context of being patient-centered and truly delivering care that meets the patient's needs, humanely.

  • SUSAN DENTZER:

    Now why was it possible to achieve all this within the VA as a system? Why is this happening at VA, and not any of the number of other places in the country where, arguably, it should have, long ago?

  • DR. PERLIN:

    I think our ability to focus on safety and quality, broadly, including compassionate health care, occurred in VA because we had to change. We recognized that people were dissatisfied with their health care, but being safe and effective was not enough. We fundamentally had to change how we delivered care, and the status quo was uncomfortable, meaning that for us perhaps change was a little easier.

    As well, we have the capacity to operate as a system, and things that may be difficult for a singular hospital or smaller health system to do, were fairly easy for us.

    For example, implementing a national electronic health record, and by the way, we like to say "electronic health record" because we believe it includes all clinical disciplines, not just doctors, and also importantly includes the patient.

    So for us to introduce an electronic health record, the question for us was not can we afford it but can we afford not to do this, and in fact I think that the history with a full deployment of electronic health record in our system has shown this was one of the best investments that we could possibly make.

    I'm not sure we could afford to give the care we do now without our electronic health record, and certainly, it's more effective, it's safer, and by being able to know why patients come to see us, or what's going on with the patient in their home, we can also deliver that care in a much more patient-centered, humane manner.

  • SUSAN DENTZER:

    What did that particular investment, to create the electronic health record cost, and what have been, what has been the dollar figure, if it's possible to arrive at one, for the total investment you've made in patient safety?

  • DR. PERLIN:

    Well, we had the opportunity to answer the question of the cost of VA's electronic health record for the, the Government Accountability Office, and we estimate that a b — a billion dollars has been invested in VA's electronic health record, and that was spread over 1300 sites of care. So, admittedly, a very sizeable number.

    I'd also note that we spend about $83 per patient per year to make the electronic health record available. I believe this is one heck of a good investment for this reason.

    According to the president's information technology advisory committee, laboratory tests are repeated, one in five times, because previous records weren't available. In fact we can pay for the cost of the electronic health record per year, per patient, by not repeating just one or two labs alone.

  • SUSAN DENTZER:

    So the cost-benefit tradeoff of this is enormous.

  • DR. PERLIN:

    It's huge. We don't spend time and money searching for paper charts, and in fact eight years ago, the rate of our paper chart being present, which is probably not different than any complex health environment, was about 60 percent.

  • SUSAN DENTZER:

    Meaning what, specifically?

  • DR. PERLIN:

    That is you came for care in VA eight years ago, the, the likelihood that your chart would be there would be 60 percent. Today, it's 100 percent.

  • SUSAN DENTZER:

    So it's another way of saying four out of ten times you showed up at a hospital or site for care, nobody knew what the heck you were there — they might know what you were there for because you were there to tell them but they wouldn't know what had happened to you before.

  • DR. PERLIN:

    You would — as with, as with our own health experiences, we go from one doctor's office to another doctor's office, we often find that we have to repeat, you know, why we're there, what the history of our illness is, and I can tell you as, not as the undersecretary, but as a doctor seeing patients, the opportunity not to have to look a patient in the eye who's there to follow up on a biopsy and to rule out cancer, and say, Could you tell me why you're here today, is, to me, the hallmark of quality. I never have to ask that question, because 100 percent of the time in VA, with the electronic health record, that information is available.

  • SUSAN DENTZER:

    And so that, again, just to make sure I understand — so you went from 40 percent of the time it not being available, to zero percent of the time it not being available, in the space of six —

  • DR. PERLIN:

    Eight years.

  • SUSAN DENTZER:

    Eight years.

  • DR. PERLIN:

    Because of our implementation of the electronic health record, over a period of eight years, we've gone from charts not being available four out of eight times, to being available every single time we see the patient.

  • SUSAN DENTZER:

    Which is really extraordinary in terms of both the benefit to the f and presumably the benefit to the providers as well.

  • DR. PERLIN:

    Absolutely. The benefit to the patient is really in terms of, of the humanity of the experience. Not to have to look a patient in the eye when they're there to follow up something absolutely critical, like a new diagnosis of cancer, and ask them why you're here today — we don't have to do that because we know we have that information.

    As for the health system, the president's information technology advisory committee published that one in five labs across the country — not in VA — across the entire country are repeated because previous records weren't available. One in seven hospitalizations occur because previous records weren't available.

    And again, across the United States, 12 percent of doctor's orders are not executed as written because of transmission errors, absent something like an electronic health record.

  • SUSAN DENTZER:

    I asked you a moment ago why this, all this was able to be achieved in the VA. By the same token, why isn't all of this being done elsewhere?

  • DR. PERLIN:

    I think — I can only speak for VA where, where the business case was very compelling for us to put in electronic health record, but I think that —

  • SUSAN DENTZER:

    You're a doctor, you have lots of colleagues who presumably went to medical schools, who are practicing in different systems across the United States. Why isn't everybody "getting religion" on this?

  • DR. PERLIN:

    I think the task seems somewhat daunting, to put in electronic health records across the country. In VA, we're a large system, we could afford to make the investment, in fact have — have said before, we couldn't afford not to make the investment.

    But for small practices, and even a singular large hospital, the investment was overwhelming, and even if they did that, I believe there are times they've not felt that they would be rewarded for that investment. In fact it might actually cost them more to provide the care.

    And so I would hope that we can move to environment where the quality is rewarded, as quality in our system has been rewarded by, by the progress.

  • SUSAN DENTZER:

    You're talking about pay-for-performance type of schemes that will essentially make it financially very beneficial for providers to move to higher standards of quality?

  • DR. PERLIN:

    Well, you know, interestingly, in VA, we don't use pay for performance. We — the reward of, of improved quality is actually being able to state that we've made that improvement, the ability to tell veterans that they're getting the top-notch care, the ability to tell veterans that for eighteen directly comparable measures of quality, quality of care and disease prevention, disease treatment, VA now sets the benchmark, it's really our reward, and so that public accountability I think is how we celebrate the success of progress and meeting our mission of caring for veterans.

  • SUSAN DENTZER:

    Which is another way of saying maybe if we just had more transparency in the rest of the health care system, everybody would have to move to a higher standard because it would be obvious that they weren't.

  • DR. PERLIN:

    I think the transparency in health care is absolutely critical. I think you as a patient, I as a patient, deserve some knowledge of the effectiveness of our health system. We deserve knowledge of the effectiveness of our doctors and our hospitals.

    In fact the doctors and the hospitals themselves can't make progress if they don't know what their level of performance is, and this is not something that can be intuitively managed. We have to measure these things, and this is really one of the areas in which VA made tremendous progress. We measure, we measure in technical quality, and as an adjunct of that in safety, we measure in access to care, satisfaction with care, restoration of function, and we hold ourselves accountable for these things and we make public our performance, and we compare our performance internally between our networks, between our hospitals, and even where I [?] practice, at Washington VA, between teams of care and we know how we're doing, and we use systems like our electronic health record in clinical decision support to help us make better choices and do better consistently.

  • SUSAN DENTZER:

    What was the hardest part of achieving the improvements in patient safety that you've achieved today?

  • DR. PERLIN:

    I think the most difficult part of making improvements in patient safety, and quality, is really a change of culture. Traditionally, people felt that high levels of professionalism would lead to the best possible outcomes, and I think we see among health care providers high levels of professionalism, and clearly, no one comes to work to do a bad job; but that's insufficient.

    To have a little sort of little natural experiment that we did. If you look at, at the rates of beta blockers, a medication that reduces your chance of dying by half after a heart attack, we find that across the country the rate is only about 50 percent, and where performance is measured, it's much, much higher, and where there's measurement and accountability, it's absolutely at the highest level.

    And so I think the knowledge of your performance is absolutely critical to make progress, and so our performance measurement throughout the VA, our holding ourselves accountable to ourselves, to the veteran, to the Congress, to the White House, and to the taxpayer, really allows us to know how we're doing, allows us to describe, quantitatively, how we're doing, and allows us to improve, to provide better care.

  • SUSAN DENTZER:

    When you talk about the cultural difficulty, though, the difficulty of the cultural change, what do you mean?

  • DR. PERLIN:

    Well, it's a big of the — the cultural difficulties are a little bit of the Lake Wobegone phenomenon, where all the kids believe they're above average, and clearly, when you actually measure health care performance, the problems are in front of us. That's what prompted the Institute of Medicine's report "To Err Is Human."

    So people, health care providers, doctors, feel that they're doing their best job and their performance must be, must be excellent.

    So if asked the question, Do you believe that there's a problem with safety? eight years ago, even in VA, doctors, nurses, health care providers, administrators would say no, we don't think there's a problem. With the Institute of Medicine report, with our own work, with our own increased knowledge, not only do we know there are issues, not just in VA but in all of health care, not only can we acknowledge them, but with that acknowledgment and with data, we can act on them.

    And so it's interesting to watch us come full circle, where, if you ask health care providers, Do errors occur in medicine? What do you think rates are? Fundamental questions that are very telling about culture, eight years ago people would have said no.

    Today they would say yes, and they would use that knowledge and that awareness to actually translate that into productive approaches to reduce, not only errors, because we're humans, we're fallible, and so the — we may not be able to completely eliminate errors — what we can do is reduce harm, build stronger systems … in terms of providing the best possible health care, the safest health care, most effective health care and the most compassionate health care.

  • SUSAN DENTZER:

    What are the next frontiers in patient safety for the VA?

  • DR. PERLIN:

    The next frontiers in patient safety — let me answer that in two ways. First, there are very — some very technical areas, and then there's some areas that a little bit more broad, technically. We, in VA, have introduced bar-coded medication administration throughout the system which reduces errors at the point of drug delivery.

    Throughout America, when you go for lab tests, someone will draw blood from you or take a biopsy specimen, and they will have a tube, a test tube, or a container, and they'll have a label. Sometimes they'll have tubes in one pocket and labels in another pocket, and that can lead, as you could quickly envision, to the wrong tube with the wrong label leading to an error.

    One of the things that we're working on at a very technical level is bar-coded laboratory acquisition. In the future in VA, every lab specimen, from blood to a skin biopsy, every lab specimen will be bar-coded so that we can make sure, as with the bar-coded medication administration, that that lab specimen belongs to you, and the right decision is made on the information that comes back from that lab test.

    So bar-coded laboratory acquisition is the new technical frontier that we're working on more broadly.

  • SUSAN DENTZER:

    And just to stop you on that. You gave a very realistic demonstration of tube in one pocket, wrong label. How does it work in a bar-coded context?

  • DR. PERLIN:

    In a bar-coded context, in contrast to me having a pocket full of labels and a pocket full of tubes, what we'll have is that tube that either has a secure individual bar code on it, that's matched with the bar code of the patient, or as when you return a rental car, someone who's drawing that la — that lab or collecting that specimen will actually have on their belt — this is the technology we're, we're looking at right now — have on their belt a scanner so they can identify that specimen, and a little printer that applies just to that, and matches the patient's bar-coded information on their wrist band with the bar code on the test tube, with the secure label that only makes sense in one context, all computerized.

    And we can do that, in part, because we have an electronic health record throughout our system, so it falls into a computerized context.

  • SUSAN DENTZER:

    And then you were saying more broadly in terms of the frontiers.

  • DR. PERLIN:

    The next frontiers of, of patient safety really, really begin to expand because there — no bright line between safety and, and quality. If I have a heart attack and don't get a drug known as a beta blocker, which reduces my chance of dying for — by half, is that unsafe? Is that poor care? I don't know. I'd say that's semantic. But we need to make sure that we've built in safety as a system property, effectiveness as a system property, and really take it down to the next level which is truly patient-centered, compassionate, humane health care. Only then do you reach effectiveness.

    After having come to VA as the chief quality officer some years ago, I think an awful lot about quality, and, ultimately, I've come to a definition which isn't very technical but I believe this really, for me, is what quality health care experience would be.

    It's when you get health care that's safe and effective, and humane, and achieves safety, effectiveness and humanity, without the need for an advocate to get through the system.

    We discovered in this field that everybody has a favorite war story, either a near miss war story or a real story where, unfortunately, there was a less — a very unfortunate outcome.

    What's your favorite war story of the type of error that happened in an earlier era but could not happen today?

  • DR. PERLIN:

    You know, doctors, health care providers traditionally don't like to, to speak about errors, but every one of us has had close calls or, or made actual mistakes, and in fact not having a patient's chart, having access, not having access to information that you should have had to, to make decisions, is something that virtually cannot occur today.

    We have a 100 percent of the patients old charts, and, and that's a great example. I think the number of times that errors at the point of, of drug administration occur in hospital have been reported as the most frequent type of error, and type of error resulting in harm to the patient.

    The bar-coded medication administration to eliminate errors at the point of drug delivery absolutely a difference, night and day, between a few years ago and VA of today.

  • SUSAN DENTZER:

    Do you look back at anything within your own experience or a story that you heard, where you just go, "Oh, my God — you know — this would never happen today"?

  • DR. PERLIN:

    Let me, let me give you an example of something that has absolutely changed the, the way we practice.

    Historically, not just in VA, across all of health care, errors have occurred during surgeries, particularly when there are two of something that you might operate on, like two knees or two hips or two arms or two eyes or two ears, and VA was actually one of the first health care system to implement secure labeling.

    So if I were having eye surgery, I would have labeled, actually, the eye, and there are a couple pieces that are absolutely important to know, is that that surgery will not go forward unless there's secure identification of the site and we actually preceded any the other national guidance on that and were able to reduce the number of wrong site surgeries, virtually eliminate wrong site surgeries, which I have to confess, occurred in VA previously, likely at the same rates as anywhere else, but by introducing this virtually eliminated that.

    We also do something that's unique as well, is that historically medicine has not been very democratic, and perhaps in the operating room there was a clear hierarchy, and I have heard stories of situations where people have known something was wrong but were afraid to speak up.

    Before every one of our surgeries in VA today, we have a mandatory time out. That is that surgery does not… occur unless that time out takes place, and that has identified errors that would otherwise have led to bad outcomes for patients.

  • SUSAN DENTZER:

    What happens when the surgery is produced within the VA?

  • DR. PERLIN:

    Even before there was any other national guidance, VA recognized that when there are two possible sites for a surgery, for instance, a knee surgery, a hip surgery or kidney surgery, or eye surgery, we need to make sure that surgery occurs on, on the correct side.

    And so we do not allow the surgery to proceed unless the patient and the doctor have had a discussion verifying that in fact it's the right site.

    For instance, if I were having eye surgery, before my surgery, I and the physician would look, review the laboratory information and this eye would be marked.

    Now this has virtually eliminated errors occurring in terms of, of the wrong side, and we have amplified that with — do you want to continue on the time out stuff or do you have that?

    By absolutely signing in indelible ink the site of surgery, this has virtually eliminated wrong-sided surgeries.

  • SUSAN DENTZER:

    In terms of the training of physicians who move through the VA system to train, as many physicians do, what impact do you think you're having on the broader health care system?

  • DR. PERLIN:

    VA provides training for about 70 percent of all physicians, and when those physicians, those physicians-in-training and all of the other health professionals, 100,000 a year, come through VA and use electronic health records, they expect that, even demand that in other health settings.

    In fact we hear from those, those, those trainees, that they've grown up with computers, they've played games on computers, they've applied to college and medical school on computers. They've possibly, you know, found their apartment, banked, and possibly even dated on computer, and they go to most of health care and they find pencil and paper.

    And in VA they use computer, they see how efficient it is. We've, we've interviewed the medical students and the other trainees and they say they wouldn't want to do this because they feel safer and they can demonstrate that they're safer by knowing why a patient's there for a particular condition.

    So we're, we're creating a generation of health professionals that will demand these tools that improve not only the patient safety, which is the first point, but their safety and effectiveness as health care providers.

  • SUSAN DENTZER:

    There's a push now, obviously, under the president's initiative and, and Dr. Braylor [ph] to extend electronic health records, medical records throughout the United States but it's uncertain how fast it's, all of this is going to move forward or where the investment is going to come to make it happen.

    How important would you say it is that this move forward as quickly as possible?

  • DR. PERLIN:

    Well, we're very proud that the president came to the Baltimore VA to launch his 10-year initiative to make electronic health records available to most Americans, and I think David Braylor's work is really moving for — field forward very quickly.

    A number of things that have been very chilling to development like absence of standards has made it very difficult to invest.

    Imagine if you were to buy a cell phone but now know if your cell phone could talk to someone else who had a different brand. Well, that's the situation we have today and what the president's strategic health information technology framework initiative is doing is helping to create these standards, and once you have these standards, all of a sudden becomes a good business proposition for people to invest in, in these health information systems.

    So we look forward to that. I should also let you know that VA, in partnership with the Department of Health and Human Services, is making a version of our electronic health record available, primarily be used in rural and underserved areas. We want to make it easy to get into that and we think it's interesting, we've already seen a number of start-up companies go out and remarket our system, develop support for it. It's free from VA. You, the taxpayer, paid for the system. You can actually have a full copy of it but may need a little bit of support getting it all started, and we're glad to see an industry starting around that because it helps to contribute to developing standards and improving health care.

  • SUSAN DENTZER:

    So what does that mean for a little community hospital system out in Podunksville, that they can actually get this off the shelf from VA?

  • DR. PERLIN:

    What, what this means for a small hospital or small practice is that they have a very inexpensive possible alternative to begin to, to use an electronic health record. We see this being used in a number of public health sites.

    For example, the D.C. Department of Public Health now uses our electronic health record to provide care in their setting.

  • SUSAN DENTZER:

    Great. Okay. That was terrific.

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