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Talking Across Degrees to Improve Patient Safety


I’m reading all this and I’m thinking . . . no one is thinking about this from a trial lawyer’s perspective – things like confidentiality are being taken for granted. No one is considering the cracks through which courts might reach to cripple even perfectly designed and implemented reporting and learning systems . . . this could cause the hard work of changing patient safety culture to come crashing down.

Last month I visited NATO as part of my fellowship’s study tour. It was actually our last stop on the tour, and after two weeks of meetings, trying to communicate in German, note taking, and traveling via bus like a rock n’ roll groupie, my brain was exhausted. When I got back to my office and looked at my scant notes from the NATO lecture, I saw the following two quotes:

"The US is the only country in the world that extends nuclear deterrence to non-nuclear allies."

"Working with non-traditional partners is part of NATO’s story today."

I know that you are hoping I’ll talk about the nuclear weapons bit, but I haven’t quite found a way to connect nuclear weapons to preventing medical negligence. I jotted down that quote, because it genuinely surprised me.

The quote about working with non-traditional partners was note-worthy, because this theme permeates my research on the modern healthcare safety agenda. In any discussion of medical negligence prevention and resolution, discipline-based alliances tend to form, and experts (MDs, RNs, MPHs, MIRMs, PhD, JDs, MBAs, etc.) work with their alphabetically-similar colleagues to propose solutions. No one really questions that the issues surrounding medical negligence involve a myriad of disciplinary fields, but there is a misconception that the pieces to this problem can be separated, worked on in an intradisciplinary fashion, and put back together for one magical collaborative solution.

One of the team members at the Institute for Patient Safety in Bonn told me that she attended a three-day conference, during which lawyers and healthcare providers met to discuss patient safety. On the last day, they realized that they were talking different languages – using different words to describe the same problem or using the same words, but with different meanings. Almost every piece of literature about patient safety and healthcare risk management begins with defining terms such as “adverse event,” “preventable adverse event,” “near-miss,” “critical incident,” “risk management,” and “quality assurance,” highlighting the problem of ever-changing key terms in the field.

As an attorney, I am often struck by the lack of attention given to legal issues that could have a critical impact on proposed solutions from healthcare providers and risk managers. On my desk sits a legal pad on which, after reading articles about using reporting and learning systems to improve patient safety culture, I scribbled the following thought:

"I’m reading all this and I’m thinking . . . no one is thinking about this from a trial lawyer’s perspective – things like confidentiality are being taken for granted. No one is considering the cracks through which courts might reach to cripple even perfectly designed and implemented reporting and learning systems . . . this could cause the hard work of changing patient safety culture to come crashing down."

Maybe I’m cynical, but after being a litigator for nearly a decade, and knowing what I know about trial judges’ discretion in discovery matters and state court judges’ (because most medical malpractice cases are litigated in state court) unwillingness to consider national (or international) policy-based reasons for rulings in individual cases, I imagine all the ways a clever plaintiff’s attorney and a sympathetic judge could throw a wrench into an expertly-designed reporting and learning system. 

As an attorney, my limitation in working on healthcare safety policy is primarily, of course, my lack of experience as a healthcare provider. This is obvious. I rely on healthcare experts to educate me about issues relating to care and the practical challenges affecting safety culture within an organization. Maybe even more obvious is my lack of knowledge regarding information technology issues. (I just Googled to make sure IT stood for “information technology.”) Internet-based reporting and learning systems require data-entry, anonymisation tools, data storage, data transmission, and many more techy-sounding words that are way outside of my area of expertise, but in many ways, are the keys to addressing my legal concerns.

I figure if NATO can reach across disciplines to develop a military strategy, then it should be possible for us to reach across disciplines to develop a healthcare safety strategy. Experts should collaborate early and often not only to offer their specialized knowledge, but also to challenge the preconceived ideas that exist within their specialties. We can and we must do better to work together to improve patient safety. Doctors, nurses, pharmacists, risk managers, healthcare administrators, lawyers, public health experts, patient advocates, healthcare policy experts, economists, IT gals and guys, insurance experts, healthcare equipment and pharmaceutical manufacturers . . . I’m looking at you!

Germany is working toward this goal through the Aktionsbündnis Patientensicherheit eV (APS), which promotes a national patient safety agenda through interdisciplinary expert working groups that develop and provide guidance on the implementation of patient safety strategies. APS recently collaborated with national patient safety organizations in Switzerland and Austria to provide recommendations for the successful implementation and operation of a critical incident reporting system (CIRS) in inpatient settings. This forty-four page guidance is based upon the current international research on improving patient safety through the use of reporting and learning systems and practical experience gained during the implementation and operation of CIRS in these three countries. Start here for recommendations in English based directly on this guidance.