Two decades ago, the Institute of Medicine shook the medical profession with its "To Err is Human" report which said nearly 100,000 people a year lost their lives to preventable medical errors.
With subsequent reports estimating that the number is likely much higher than that, more health systems have been seeking to find ways to engineer the possibility of human error out of their healthcare delivery.
During the 7th Annual World Patient Safety, Science & Technology Summit over the weekend, the Patient Safety Movement Foundation released a new tool on its website to help with the training.
The patient safety curriculum is one of 17 Actionable Patient Safety Solutions (APSS) made available to organizations for free to help train health professionals in systems science so they can help find ways to reduce preventable patient deaths, officials said.
“The goal is to get every health professional to think in a system way,” said Steven Scheinman, M.D., the president and dean of Geisinger Commonwealth School of Medicine. He led a Patient Safety Movement working group which included experts from Geisinger, San Diego State, University of Pittsburgh Medical Center, Johns Hopkins Health, and MedStar Georgetown to develop the curriculum over an 18-month period.
The Patient Safety Movement was founded in 2013 to help reduce preventable deaths in healthcare and in 2015 set a goal of zero preventable deaths by 2020. More than 90,000 patients who might have died as a result of medical errors were saved in 2018 due to efforts made by more than 4,700 hospitals that committed to patient safety efforts, according to figures released by the foundation. In all, a total of 273,077 lives have been saved since the first summit, officials said.
"We want to train every health professional to take ownership of the patient’s safety and experience so they understand safe communication and know when they are telling another person about the patient or handing them over or referring them over, how to make sure they get all the critical information there," Scheinman said.
Already, the Patient Safety Movement has released multiple APSS centered on training medical professionals to avoid medical errors in the clinical setting when it comes to catheter infections or problems with airway management. This curriculum teaches system science itself so more health professionals will be trained to think about how certain factors in the handoff of information between shifts, or a particular workflow on an EHR, might be contributing to errors.
"The airline industry solved safety by creating the right systems," Scheinman said. "Medical errors are very widespread. But they usually aren’t a doctor making a mistake. They can be. But they’re more often the system failed to pick something up or allowed something bad to happen."
And with this training, he said, those medical professionals might be that much more likely to help figure out a new solution to make sure something bad doesn't happen again.