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VA Hospital Takes Steps to Avoid Medical Mistakes

Studies show thousands of Americans are killed or injured each year due to avoidable mistakes. Susan Dentzer looks at how one health care system is trying to stop medical errors before they happen.

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  • JIM LEHRER:

    Now, preventing medical errors before they lead to deadly consequences. Susan Dentzer of our health unit has a look at how one health care system is dealing with that problem. The unit is a partnership with Henry J. Kaiser Family Foundation.

  • DR. ROSS FLETCHER:

    Good morning, Mr. Hilliard. How are you doing?

  • SUSAN DENTZER:

    When Dr. Ross Fletcher visits patients here at the Washington, D.C. Veterans' Administration Hospital, he knows he should first cleanse his hands.

    A quick rub with an alcohol-foam disinfectant can help prevent the spread of bacterial infections. Those kill tens of thousands of hospital patients every year.

  • DR. ROSS FLETCHER:

    Take a deep breath.

  • SUSAN DENTZER:

    Most health care providers know they should follow the hand-cleansing procedure, but they don't always do it. Fletcher says the VA decided to change that.

  • DR. ROSS FLETCHER:

    When we first started this program, we noticed that about 40 percent of the time hand cleansing occurred satisfactorily.

    More recently it's been more well into the 80 percent range and we hope to get it close to 100 percent, so that any patient requiring hand cleansing will have that happen. What we've noticed in addition is that using the alcohol foam cleansing agent, we've been able to further reduce, over just simple hand washing, the incidence of very serious antibiotic resistant infections.

  • SUSAN DENTZER:

    The VA managed to double the rate of hand cleansing in the simplest of ways, for instance by putting disinfectant dispensers right here on the walls of patients' rooms. It's a small change that saves both money and lives, and it's just the sort of measure called for five years ago in this blockbuster report by the Institute of Medicine.

    Titled "To Err is Human," the 1999 report estimated that avoidable errors in U.S. hospitals were killing 44,000 to 98,000 Americans a year. They were injuring thousands more.

    The report said that was the equivalent of a jumbo jet crashing every day. One of the report's authors was Dr. Lucian Leape of the Harvard School of Public Health.

  • DR. LUCIAN LEAPE:

    The Institute of Medicine report in 1999 called for a national commitment, a moon shot, I mean, a serious national effort to reduce medical errors. We said we could reduce medical errors by 50 percent in five years if we had that kind of national commitment.

  • SUSAN DENTZER:

    But Leape and other safety experts say that national commitment failed to materialize.

  • DR. ROSS FLETCHER:

    There's been a bill before Congress every year for the last four years to provide protection, and we just don't seem to be able to get it passed.

  • SUSAN DENTZER:

    Dr. Robert Wachter of the University of California at San Francisco co-authored a book on patient safety.

  • DR. ROBERT WACHTER:

    Everybody — every doctor, everybody, every nurse, every hospital administrator — knows we have a terrible problem and they really are desperate. I mean, just think about if a jumbo jet was crashing every day what we would be doing to solve that problem.

  • SUSAN DENTZER:

    If there's good news, say these safety experts, it's that despite the lack of national commitment, some health systems like the VA are taking steps to solve problems.

    Dr. Jonathan Perlin, who heads the VA health system, acknowledges that was not always the case.

  • DR. JONATHAN PERLIN:

    It's fair to say that historically, the VA's reputation was not — was not perfect and we realized we needed to change and what we saw was that we needed to improve safety, improve quality and improve the compassion with which we delivered care.

  • SUSAN DENTZER:

    So to lead its own moon shot against medical errors, the VA picked this man, physician and former astronaut James Bagian. Among other things, Bagian had helped to investigate space shuttle disasters at NASA. He thought aviation and aerospace had plenty to teach health care.

  • DR. JAMES BAGIAN:

    An air-mail pilot back in the thirties had a life expectancy on the job of three to four years. And it wasn't until the '50s that aviation really started looking and saying, we can't just keep building more planes when we crash them.

  • SUSAN DENTZER:

    So aviation developed a so-called systems approach to improving safety. That includes an emphasis on teamwork and fixed procedures; those prevent airline crews from making mistakes, or provide a backstop to thwart crashes in the event that errors occur.

  • DR. JAMES BAGIAN:

    It was understanding, "we standardize." It's not like everybody has their own little way they want to fly the plane. We said, there are certain ways to do it; that we use checklists for certain things; that, you know, you take away certain latitudes.

  • SUSAN DENTZER:

    Bagian says applying systems-thinking to VA health care started with a similar cultural change. Rather than burying mistakes or punishing people involved in them, the VA had to ferret them out.

    Borrowing another leaf from airline safety, VA personnel are now required to report any adverse events through an internal computerized reporting system. They're also required to report so-called "near-misses" or "close calls"– instances when something dangerous almost happens to patients but doesn't.

  • DR. JAMES BAGIAN:

    Close calls happen anywhere from 10 to 200 times more frequently than the event they're the precursor of. So you can think of for every incorrect surgery that's done, there's anywhere from 10 to 200 that almost happened. Why not learn from those?

  • SUSAN DENTZER:

    Bagian simulated for us how the reporting system works.

  • DR. JAMES BAGIAN:

    Patient almost had surgery performed on the incorrect leg.

  • SUSAN DENTZER:

    VA safety experts analyze these reports and then launch a so-called root cause analysis. That's when a small team is assembled to probe the chain of factors leading up to a given adverse event.

    Take the problem Bagian simulated: Operating on the wrong site of the patient's body. It's surprisingly common throughout U.S. Hospitals, especially when surgery involves a part that the body has two of, like eyes or kidneys.

    To avoid wrong-site surgery, a national hospital oversight body, the Joint Commission for Accreditation of Healthcare Organizations, now requires that the correct surgical site be clearly marked. But Bagian says that when VA performed root-cause analysis, it discovered an even bigger problem.

  • DR. JAMES BAGIAN:

    We found that 44 percent of incorrect surgeries — that's what we call them; we don't call them wrong-sited, because that's not right — 44 percent were left/right foul-ups; 36 percent were the wrong patient. The reason they did the wrong knee was they thought I was you.

  • SUSAN DENTZER:

    The solution was to adopt a protocol in which each patient to be operated on first identifies himself by name, birth date and Social Security number.

  • PATIENT:

    William Dreyer.

  • HEALTH CARE WORKER:

    OK, and your birth date?

  • PATIENT:

    Feb. 10, 1947.

  • HEALTH CARE WORKER:

    OK, and your Social Security number?

  • SUSAN DENTZER:

    We watched the process take place before a real-life surgery at the Washington, D.C. Veterans' Medical Center.

    Bagian says that when these procedures have been followed at VA, they've drastically reduced wrong-site or wrong-person surgery. Another change from the past is that the VA now relies heavily on information technology to thwart errors, especially those involving medication.

    Studies suggest those turn up in roughly one out of every six hospital stays throughout the U.S. As a result, the VA has shifted to an almost fully computerized medication system. Physicians first select the name of the drug they want to prescribe, and the correct dose, from a computerized menu.

    That prevents any mistakes stemming from doctors' often unreadable handwriting. The physician can then check the prescription against the patient's fully electronic health record to probe any concerns about allergies or adverse drug interactions.

    The VA is the first large health system in the nation to replace paper charts with this fully electronic record. The VA spent more than a billion dollars developing the record, but it now costs just $78 per patient per year to operate, and Perlin says it produces a huge safety payoff.

  • DR. JONATHAN PERLIN:

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

  • SUSAN DENTZER:

    Once a prescription order is checked against the electronic health record, it's routed to the hospital pharmacy, where medication is labeled with the patient's name and a unique barcode. That's an innovation dreamed up by a VA nurse, who saw the bar coding technology in use at a car rental agency and suggested it could be adapted by the VA

  • DR. JONATHAN PERLIN:

    The nurse scans the barcode 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, and virtually eliminating errors at that point of administration.

  • SUSAN DENTZER:

    On the day we visited the Washington VA, inpatient Charles Hilliard was getting his medicine for leukemia.

  • CHARLES HILLIARD:

    There was two Hilliards on this floor, so I definitely don't want to get his medicine, and I imagine he didn't want to get mine either! So with the barcode thing, I'll get the right medicine.

  • SUSAN DENTZER:

    The VA now plans to add bar coding technology to lab work to prevent mix ups in which one patient's specimens are confused with another's.

    With the exception of the costly step of converting to electronic health records, most of these changes have come cheaply. They amount to ten cents for every $100 the VA spends on delivering medical care.

    A new report from the government accountability office, Congress's watchdog arm, gives the VA generally high marks for its safety initiatives.

    At the same time, the report urges even broader cultural changes. Among other things, it said, "Nurses need the confidence to disagree with physicians when they find an unsafe situation."

    VA officials agree and say they've already launched training programs to encourage nurses to do just that. They say that's just one way they're aiming for still higher levels of patient safety and hoping to set a standard for other U.S. health care providers to follow.

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