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INTRODUCTION

KEY QUESTIONS

  • What is the importance of an interdisciplinary team-care model vs. an autonomous single-provider-care model in the provision of patient safety?

  • Can you identify three characteristics of the highly reliable organization, and their impact on patient safety?

  • What is the value of self-reported errors in improving patient safety?

An outpatient infusion center receives paper orders (often as simple as scraps of paper left on the desk of the pharmacy technician) from oncologists to prepare chemotherapy for patients who will commence or continue their therapies over the next several weeks. Just before patients arrive on the day of their scheduled therapy, the technician has prepared and delivered the infusate to the nursing station. No one else sees the order prior to the preparation of the drug. While some orders follow national protocol guidelines, many are “innovative and cutting-edge,” often based upon individual papers or abstracts encountered by an oncologist on the preceding day. On several occasions, orders were incorrect, sometimes due to significant changes in patient body weights or creatinine levels occurring between the last outpatient visit to the oncologist and the infusion date. These were recognized only because the dedicated pharmacy technologist would review patients’ charts for the most recent findings and then recalculate the doses himself.

On a day that he was on vacation, the substitute technologist did not recognize that an oncologist's medical assistant had recorded the patient's weight of 168 lb as “168” in the electronic health record (EHR), which only recognized weights in kilograms. This error, the regular technologist later explained, was common, and he would always look for impossible (or extremely unlikely) changes in weight before calculating doses. In this instance, due to the inaccurate weight record, more than double the dose of chemotherapy was ordered, prepared, and administered. Nine days later, the patient perished in the intensive care unit (ICU) with sepsis and multisystem failure.

First, do no harm. The safety of patients is the most important principle of healthcare delivery. Each member of the healthcare team must put the safety of the patient above all other goals. Yet we continue to fail tragically in this effort to protect our patients from iatrogenic, avoidable errors that cause harm. A 1999 report from the Institute of Medicine (IOM) alerted the healthcare industry, insurers, and the various medical professions to the remarkably undernoticed magnitude of patient harm occurring across the nation. IOM's original estimation of up to 100,000 unnecessary patient deaths annually is now considered low.

Yet, given the highly complex nature of healthcare delivery, this tendency to err should not be a surprise. Scientific inquiry in the areas of organizational behavior, system dynamics, and human factors engineering has discerned that highly complex organizations naturally tend to see increased risks over time. Healthcare's evolving technology and lack of concordant attention to scrutiny of its impact on safety, as well as the need for changes in ...

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