MedStar Health: Using A Multi-Disciplinary Approach to Catch Medical Errors Before They Occur

Hundreds of near misses occur for each adverse event in complex industries, according to James Reason’s research, yet many health systems continue to try to solve the medical error problem by focusing on the proverbial needle in the haystack, which still occurs all too frequently. So frequently in fact, that the World Health Organization recently reported the odds of dying due to a medical error to be 1 in 300 compared to the likelihood of dying in an airline crash, which they estimate to be 1 in 10 million.

But the MedStar Health System in Maryland and Washington DC is increasing their odds of finding a new way to prevent medical errors before they occur. Leadership at this innovative health system is successfully collaborating across multi-disciplinary lines with safety scientists, innovation researchers, safety & quality leadership and their simulation center, SiTel, coming together to move patient safety into the 21st century. Instead of waiting for a medical error to occur, Terry Fairbanks MD, MS (Director), Zach Hettinger MD, MS and their team at the National Center for Human Factors of Engineering in Healthcare are taking into account the opportunity those hundreds of near misses present, and the team is looking to test their Integrated Patient Safety Transformational (PST) Model which provides a proactive approach to medical error prevention, catching errors before they occur.

If medical error should occur, the PST model also includes the same tenets of disclosure and transparency the 7 Pillars approach is based upon, and which received a $3M AHRQ grant in 2010. David Mayer MD, our blog host and now VP of Safety & Quality at MedStar, is co-Principal Investigator on the 7 Pillars grant, along with Principal Investigator Tim McDonald MD/JD at the University of Illinois-Chicago Medical Center. With Mayer’s arrival at MedStar in May of this year, it was apparent that Fairbanks’ human factors work raised the 7 pillars to new heights (and vice versa). The model was now complete by providing an organized and optimized advanced response to adverse events with an emphasis on improving safety and reducing liability risk before error occurs, but also having a progressive approach to work with patients, families and caregivers if events do occur.

A description of the PST model, and the origin of its genesis will be provided in tomorrow’s post. In the meantime, please share your innovative ideas around preventing medical error and keeping patients safe.


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