Portal de Periódicos da CAPES

Safety in Interventional Radiology

2007; Elsevier BV; Volume: 18; Issue: 1 Linguagem: Inglês

10.1016/j.jvir.2006.10.007

1535-7732

Donald L. Miller,

Clinical Reasoning and Diagnostic Skills

You land a million planes safely, then you have one little mid-air and you never hear the end of it.Air Traffic Controller, New York TRACON, Westbury Long Island.Opening quotation from the movie Pushing Tin (1Great aviation quotes. http://www.skygod.com/quotes/safety.html. Accessed October 12, 2006.Google Scholar) Complacency or a false sense of security should not be allowed to develop as a result of long periods without an accident or serious incident. An organization with a good safety record is not necessarily a safe organization.International Civil Aviation Organization, Accident Prevention Manual (1Great aviation quotes. http://www.skygod.com/quotes/safety.html. Accessed October 12, 2006.Google Scholar) Every accident, no matter how minor, is a failure of the organization.Jerome Lederer (1Great aviation quotes. http://www.skygod.com/quotes/safety.html. Accessed October 12, 2006.Google Scholar) Mishaps are like knives that either serve us or cut us as we grasp them by the blade or the handle.James Russell Lowell (1Great aviation quotes. http://www.skygod.com/quotes/safety.html. Accessed October 12, 2006.Google Scholar)THIS issue of the journal inaugurates a new feature—Interventional Radiology (IR) Safety Rounds—devoted to improving patient safety by eliminating sources of preventable medical error.It should no longer be news to any of us that preventable medical errors occur in our healthcare system. Beginning in the early 1990s, articles by Leape and others (2Leape L.L. Brennan T.A. Laird N. et al.The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II.N Engl J Med. 1991; 324: 377-384Crossref PubMed Scopus (2887) Google Scholar, 3Leape L.L. Bates D.W. Cullen D.J. et al.Systems analysis of adverse drug events: ADE Prevention Study Group.JAMA. 1995; 274: 35-43Crossref PubMed Scopus (1744) Google Scholar, 4Brennan T.A. Leape L.L. Laird N.M. et al.Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I—1991.Qual Saf Health Care. 2004; 13: 145-152Crossref PubMed Scopus (332) Google Scholar, 5Bates D.W. Cullen D.J. Laird N. et al.Incidence of adverse drug events and potential adverse drug events: implications for prevention.JAMA. 1995; 274: 29-34Crossref PubMed Scopus (2730) Google Scholar) highlighted the frequency of adverse events in the American healthcare system. Public attention was aroused when the Institute of Medicine published its report To Err Is Human: Building a Safer Health Care System in 1999 (6Kohn L.T. Corrigan J.M. Donaldson M.S. To err is human: building a safer health care system. National Academy Press, Washington, DC1999Google Scholar). In that report, it was estimated that 44,000–98,000 hospitalized Americans died in 1997 as a result of preventable medical errors. This is the equivalent in loss of life to one or two full Boeing 737 aircraft crashing every day of the year. These figures do not include those patients who are injured as a result of medical errors but do not die. Some believe that the Institute of Medicine may have overstated the case (7Brennan T.A. The Institute of Medicine report on medical errors: could it do harm?.N Engl J Med. 2000; 342: 1123-1125Crossref PubMed Scopus (238) Google Scholar, 8McDonald C.J. Weiner M. Hui S.L. Deaths due to medical errors are exaggerated in Institute of Medicine report.JAMA. 2000; 284: 93-95Crossref PubMed Scopus (251) Google Scholar). Nonetheless, it is clear that preventable medical errors occur at unacceptable rates throughout our healthcare system.Patient safety is being addressed at multiple levels throughout our healthcare system and by many groups and organizations (9Borgstede J.P. Zinninger M.D. Radiology and patient safety.Acad Radiol. 2004; 11: 322-332Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar). Perhaps most obvious to anyone who works in a hospital setting are the recent initiatives and emphasis on patient safety of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which accredits healthcare organizations on the basis of evaluations of the quality and safety of care. As part of this emphasis, the JCAHO promotes national patient safety goals and has established a sentinel event policy calling for the identification, reporting, evaluation, and prevention of sentinel events. According to the JCAHO, a sentinel event is “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof” (10Joint Commission on Accreditation of Healthcare Organizations. Sentinel event policy and procedures. http://www.jointcommission.org/SentinelEvents/PolicyandProcedures/. Accessed October 12, 2006.Google Scholar). The terms sentinel event and medical error are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events (10Joint Commission on Accreditation of Healthcare Organizations. Sentinel event policy and procedures. http://www.jointcommission.org/SentinelEvents/PolicyandProcedures/. Accessed October 12, 2006.Google Scholar). The JCAHO requires that all sentinel events be investigated by using root cause analysis and that the results of the investigation be reported to it.Root cause analysis is a powerful tool for analyzing system failures and is equally applicable to actual adverse events and to “close calls.” In this issue of the journal, Stecker (11Stecker M.S. Root cause analysis.J Vasc Interv Radiol. 2007; 18: 5-8Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar) inaugurates the IR Safety Rounds series with an introduction to this analytical tool and how it is used. The basis for root cause analysis is the recognition that most of the problems in the healthcare system are due to system failures rather than the performance of individuals (12Thrall J.H. Quality and safety revolution in health care.Radiology. 2004; 233: 3-6Crossref PubMed Scopus (52) Google Scholar). Both root cause analysis and the understanding that bad systems will triumph over good people are outgrowths of the aviation industry. One of my colleagues, a former Navy flight surgeon, was initially unfamiliar with root cause analysis but recognized it immediately as analogous in concept and structure to the review that is performed after naval aviation mishaps.We all must be on our guard constantly to keep our patients safe. One way to do this is to read, understand, and follow the relevant practice guidelines issued by the American College of Radiology (ACR) and the SIR (13American College of Radiology2006 practice guidelines & technical standards. American College of Radiology, Reston, Va2006Google Scholar, 14Society of Interventional Radiology. Quality improvement documents. http://www.sirweb.org/clinical/all.shtml, Accessed October 12, 2006.Google Scholar). In addition, we must make the transition from the old culture of blame (“you screwed up”) to a culture of safety (“let’s find out what the problem is and fix the system”). An essential component of a culture of safety is sharing and disseminating experience with sentinel events. Some of the analyses of adverse events submitted to the JCAHO are published as Sentinel Event Alerts and are available at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/. Most of these are not directly relevant to the practice of interventional radiology. The purpose of the IR Safety Rounds series is to provide a forum for publicizing lessons learned that are relevant to interventional radiology. The journal plans to publish examples submitted by our readers. I encourage all SIR members to submit manuscripts based on their experiences. The format for these submissions is given elsewhere in the journal.What kinds of events should be submitted? Essentially, any adverse event or potential adverse event (“close call”) that occurs in our daily practice can be submitted. In our specialty, a wide variety of circumstances have the potential to lead to a preventable adverse outcome. The National Quality Forum has published a standardized list of 27 serious preventable adverse events (15The National Quality ForumSerious reportable events in healthcare: a consensus report. The National Quality Forum, Washington, DC2002Google Scholar). The ACR Task Force on Patient Safety has identified a number of preventable errors, most of which are relevant to interventional radiology (9Borgstede J.P. Zinninger M.D. Radiology and patient safety.Acad Radiol. 2004; 11: 322-332Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar). The ACR list is by no means exhaustive. The SIR Task Force on Medical Errors, a predecessor to the present Safety and Health Committee, also compiled a list of preventable medical errors (Figure). This list, too, is without doubt incomplete. The important thing is that the report of the event is accompanied by an analysis of what went wrong, why it happened, and what system changes are needed to keep it from recurring. Only in this way can we all learn how to improve our practices. Our patients deserve no less.FigurePossible causes of preventable adverse events. Adapted from a list developed by the SIR Medical Errors Task Force. This is not intended as a comprehensive or complete list. (continues)View Large Image Figure ViewerDownload Hi-res image Download (PPT) You land a million planes safely, then you have one little mid-air and you never hear the end of it. Air Traffic Controller, New York TRACON, Westbury Long Island. Opening quotation from the movie Pushing Tin (1Great aviation quotes. http://www.skygod.com/quotes/safety.html. Accessed October 12, 2006.Google Scholar) Complacency or a false sense of security should not be allowed to develop as a result of long periods without an accident or serious incident. An organization with a good safety record is not necessarily a safe organization. International Civil Aviation Organization, Accident Prevention Manual (1Great aviation quotes. http://www.skygod.com/quotes/safety.html. Accessed October 12, 2006.Google Scholar) Every accident, no matter how minor, is a failure of the organization. Jerome Lederer (1Great aviation quotes. http://www.skygod.com/quotes/safety.html. Accessed October 12, 2006.Google Scholar) Mishaps are like knives that either serve us or cut us as we grasp them by the blade or the handle. James Russell Lowell (1Great aviation quotes. http://www.skygod.com/quotes/safety.html. Accessed October 12, 2006.Google Scholar) THIS issue of the journal inaugurates a new feature—Interventional Radiology (IR) Safety Rounds—devoted to improving patient safety by eliminating sources of preventable medical error. It should no longer be news to any of us that preventable medical errors occur in our healthcare system. Beginning in the early 1990s, articles by Leape and others (2Leape L.L. Brennan T.A. Laird N. et al.The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II.N Engl J Med. 1991; 324: 377-384Crossref PubMed Scopus (2887) Google Scholar, 3Leape L.L. Bates D.W. Cullen D.J. et al.Systems analysis of adverse drug events: ADE Prevention Study Group.JAMA. 1995; 274: 35-43Crossref PubMed Scopus (1744) Google Scholar, 4Brennan T.A. Leape L.L. Laird N.M. et al.Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I—1991.Qual Saf Health Care. 2004; 13: 145-152Crossref PubMed Scopus (332) Google Scholar, 5Bates D.W. Cullen D.J. Laird N. et al.Incidence of adverse drug events and potential adverse drug events: implications for prevention.JAMA. 1995; 274: 29-34Crossref PubMed Scopus (2730) Google Scholar) highlighted the frequency of adverse events in the American healthcare system. Public attention was aroused when the Institute of Medicine published its report To Err Is Human: Building a Safer Health Care System in 1999 (6Kohn L.T. Corrigan J.M. Donaldson M.S. To err is human: building a safer health care system. National Academy Press, Washington, DC1999Google Scholar). In that report, it was estimated that 44,000–98,000 hospitalized Americans died in 1997 as a result of preventable medical errors. This is the equivalent in loss of life to one or two full Boeing 737 aircraft crashing every day of the year. These figures do not include those patients who are injured as a result of medical errors but do not die. Some believe that the Institute of Medicine may have overstated the case (7Brennan T.A. The Institute of Medicine report on medical errors: could it do harm?.N Engl J Med. 2000; 342: 1123-1125Crossref PubMed Scopus (238) Google Scholar, 8McDonald C.J. Weiner M. Hui S.L. Deaths due to medical errors are exaggerated in Institute of Medicine report.JAMA. 2000; 284: 93-95Crossref PubMed Scopus (251) Google Scholar). Nonetheless, it is clear that preventable medical errors occur at unacceptable rates throughout our healthcare system. Patient safety is being addressed at multiple levels throughout our healthcare system and by many groups and organizations (9Borgstede J.P. Zinninger M.D. Radiology and patient safety.Acad Radiol. 2004; 11: 322-332Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar). Perhaps most obvious to anyone who works in a hospital setting are the recent initiatives and emphasis on patient safety of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which accredits healthcare organizations on the basis of evaluations of the quality and safety of care. As part of this emphasis, the JCAHO promotes national patient safety goals and has established a sentinel event policy calling for the identification, reporting, evaluation, and prevention of sentinel events. According to the JCAHO, a sentinel event is “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof” (10Joint Commission on Accreditation of Healthcare Organizations. Sentinel event policy and procedures. http://www.jointcommission.org/SentinelEvents/PolicyandProcedures/. Accessed October 12, 2006.Google Scholar). The terms sentinel event and medical error are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events (10Joint Commission on Accreditation of Healthcare Organizations. Sentinel event policy and procedures. http://www.jointcommission.org/SentinelEvents/PolicyandProcedures/. Accessed October 12, 2006.Google Scholar). The JCAHO requires that all sentinel events be investigated by using root cause analysis and that the results of the investigation be reported to it. Root cause analysis is a powerful tool for analyzing system failures and is equally applicable to actual adverse events and to “close calls.” In this issue of the journal, Stecker (11Stecker M.S. Root cause analysis.J Vasc Interv Radiol. 2007; 18: 5-8Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar) inaugurates the IR Safety Rounds series with an introduction to this analytical tool and how it is used. The basis for root cause analysis is the recognition that most of the problems in the healthcare system are due to system failures rather than the performance of individuals (12Thrall J.H. Quality and safety revolution in health care.Radiology. 2004; 233: 3-6Crossref PubMed Scopus (52) Google Scholar). Both root cause analysis and the understanding that bad systems will triumph over good people are outgrowths of the aviation industry. One of my colleagues, a former Navy flight surgeon, was initially unfamiliar with root cause analysis but recognized it immediately as analogous in concept and structure to the review that is performed after naval aviation mishaps. We all must be on our guard constantly to keep our patients safe. One way to do this is to read, understand, and follow the relevant practice guidelines issued by the American College of Radiology (ACR) and the SIR (13American College of Radiology2006 practice guidelines & technical standards. American College of Radiology, Reston, Va2006Google Scholar, 14Society of Interventional Radiology. Quality improvement documents. http://www.sirweb.org/clinical/all.shtml, Accessed October 12, 2006.Google Scholar). In addition, we must make the transition from the old culture of blame (“you screwed up”) to a culture of safety (“let’s find out what the problem is and fix the system”). An essential component of a culture of safety is sharing and disseminating experience with sentinel events. Some of the analyses of adverse events submitted to the JCAHO are published as Sentinel Event Alerts and are available at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/. Most of these are not directly relevant to the practice of interventional radiology. The purpose of the IR Safety Rounds series is to provide a forum for publicizing lessons learned that are relevant to interventional radiology. The journal plans to publish examples submitted by our readers. I encourage all SIR members to submit manuscripts based on their experiences. The format for these submissions is given elsewhere in the journal. What kinds of events should be submitted? Essentially, any adverse event or potential adverse event (“close call”) that occurs in our daily practice can be submitted. In our specialty, a wide variety of circumstances have the potential to lead to a preventable adverse outcome. The National Quality Forum has published a standardized list of 27 serious preventable adverse events (15The National Quality ForumSerious reportable events in healthcare: a consensus report. The National Quality Forum, Washington, DC2002Google Scholar). The ACR Task Force on Patient Safety has identified a number of preventable errors, most of which are relevant to interventional radiology (9Borgstede J.P. Zinninger M.D. Radiology and patient safety.Acad Radiol. 2004; 11: 322-332Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar). The ACR list is by no means exhaustive. The SIR Task Force on Medical Errors, a predecessor to the present Safety and Health Committee, also compiled a list of preventable medical errors (Figure). This list, too, is without doubt incomplete. The important thing is that the report of the event is accompanied by an analysis of what went wrong, why it happened, and what system changes are needed to keep it from recurring. Only in this way can we all learn how to improve our practices. Our patients deserve no less.