Better systems the key to improving safety, reducing errors

James S. Taylor, MD: “The key is changing the culture in dealing with errors.”

James S. Taylor, MD: “The key is changing the culture in dealing with errors.”

“First, do no harm” is a tenet and a challenge in the constantly changing universe of health care. The challenge, though, lies more in the basic systems of care rather than the expanding treatment options based on complex science.

“One of the important premises of the patient safety movement is that it is based on system issues as much as individual issues, so it is not just the actions of an individual. We don’t try to intentionally harm somebody, but because of pressures of the job — rushing and other factors — errors occur,” said James S. Taylor, MD, who delivered the Everett C. Fox, MD, Memorial Lecture during the Friday Plenary session.

Dr. Taylor, quality improvement officer at the Dermatology & Plastic Surgery Institute at the Cleveland Clinic, examined key patient safety issues during his address, “To Err Is Human: Optimizing Patient Safety in Office Practice,” and in an exclusive interview on the topic to AAD Meeting News.

The patient safety movement began 20 years ago following reports of operating room deaths linked to anesthesia, so the initial emphasis was on hospitals, but it is now moving to individual practices, Dr. Taylor said.

“The reason it has been primarily focused on hospitals is because hospital payments have been based in part — and will be increasingly based — on specific measures that are reported publicly on patient safety indicators and quality measures,” he said. “But it is important that we move it to the ambulatory arena, and dermatologists are particularly positioned to address the issues in the ambulatory arena.”

A starting point in improving safety is accepting that errors are inevitable, and many are due to systems issues rather than individual errors, Dr. Taylor said. This should relieve individual pressure and spread it to treatment teams that should identify risks and vulnerabilities, with a focus on voluntary self-reporting of errors.

“The key is changing the culture in dealing with errors. People don’t want to report them, or tell patients they made a mistake, or even apologize to them,” he said. “The key is to change the culture. Systems are important, but people still matter. You have to think about what you are doing, and balance no-blame and accountability.

“Teamwork is the part of the system where you engage everybody in your office to have high reliability in dealing with errors. It is critical to think that if it can go wrong, it will go wrong.”

The term “just culture” has come to recognize that individuals should not be accountable for system failures they cannot control. This culture also recognizes that errors occur in interactions between individuals and systems, but it does not tolerate conscious disregard of risks or gross misconduct.

System changes that can be implemented to reduce errors, Dr. Taylor said, should start with basics. A common error is patient misidentification, which leads to medication errors, lab processing errors, and wrong-person procedures.

To prevent patient identification errors, a system should require two identifiers, such as confirming the patient’s name and date of birth. Room numbers and telephone numbers should be avoided, he said.

To prevent medication errors, it is important to identify the patient, avoid look-alike/ sound-alike medicines, do away with verbal orders, and review prescriptions. Checklists are helpful in avoiding these potential errors, Dr. Taylor said.

Another common error involves wrong-site surgeries, including biopsy site identification. Preventive actions should include marking the site, taking “time out” to confirm details, detailed anatomic descriptions, diagrams, and photography.

A third area of concern is the processing of pathology specimens. To prevent confusion, a precise written uniform protocol for each specimen is important. Dr. Taylor said other good system processes include communicating results to patients, recording results in the patient chart, and using checklists.

Other sources of errors and threats to safety include:

  • Sharps injuries, which occur during surgeries, biopsies, and injections, often because of rushing or working in an awkward posture.
  • Occupational health threats, which can be prevented with double-gloving and wearing protective shoes.
  • Workplace violence, which is uncommon. However, health care professionals should be cognizant of unhappy patients, particularly if cosmetic or surgery outcomes are not good.

The Academy began taking steps to help members reduce errors and improve safety by starting a Patient Safety and Quality Committee in 2008, chaired by Dr. Taylor, and offering courses at the Annual Meeting and Summer Academy Meeting. Also, an ad hoc task force on data collection has been developed with a goal of launching the DataDerm ambulatory registry. DataDerm will be used to collect data from electronic medical records about errors starting in 2016, Dr. Taylor said.

“The key is to change the culture in practices and convince people this is important, and that patient safety is more than a statement of fact,” Dr. Taylor said. “One has to think about it, implement it, and sustain it. The changes to prevent medical errors that may be implemented lie in a root cause analysis to figure out why they occurred. We need to think about it as a systems issue rather than an individual issue.”

As he closed his Plenary address, Dr. Taylor added, “Make the right thing to do the only option.”

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