Risk Manager

Cleland tracks medical errors, improves patient safety

Risk management is often compared to Swiss cheese.

Patient-safety policies serve as a series of roadblocks in the Swiss cheese so that if a misstep gets through one hole, hopefully another block will stop it.

“When you find an error, the holes in the Swiss cheese lined up just so that it impacted the patient,” said Dr. William Cleland, medical director of risk management for University Hospitals and Health System. “A lot of our errors are system-driven, and our job is to find out what happened that allowed us to make this error.”

Cleland, associate professor of obstetrics and gynecology, became medical director after joining the risk management committee four years ago. He and four nurse coordinators are working to increase reporting of adverse events through departmental meetings and presentations to residents, and the results have been positive.

Often they pore through 50-200 occurrence reports weekly from medical staff and patients, ranging from complaints about staff conduct to cold food to patient care errors. The goal for the more serious reports is to analyze the root causes why an incident happened and figure out what procedures need to be implemented to prevent future errors.

“The No. 1 benefit is patient safety. We’re not going to be able to get better if we don’t know what our problems are. Our pathway to do that is occurrence reporting,” Cleland said.

“Hand in hand with that is reduction of medical errors. We want this institution to be the best hospital in the region, so patient satisfaction and outcome is very important to us.”

Dr. James Keeton, interim vice chancellor for health affairs, has visited departments to talk about the importance of risk management. He said tracking adverse events and correcting them is required by the Joint Commission.

“It’s part of what we should do and it’s just the right thing to do,” he said.

Cleland said there are different levels of risk management at all academic medical institutions, and the concept is still relatively new.

“The medical industry is way behind other industries when it comes to risk management,” he said. “I think it’s because of the nature of being transparent and learning to analyze why mistakes are made. Admitting mistakes is very difficult for the medical field because of fear of litigation.”

Mary Taylor, director of patient safety for the Washington University School of Medicine Faculty Practice Plan in St. Louis, said the process takes time to establish, but if it’s done properly, it works. She said the change in attitudes has been slow but steady at her institution.

She attributes the success to easier reporting of events, a safe environment for staff and residents to share information, and a focus on what happened, not who did it.

"Physicians tend to take it all on their shoulders,” Taylor said. “It’s very helpful to show that there’s a cascade of events that occurred. They had a role in it, but so did a lot of people.

“It’s hard for them to accept that just working harder and being more vigilant won’t fix the process. They are a part of a team and a process, which needs to support their work, not make it more difficult.”

Safety policies, such as “time outs” before surgeries, have helped reduce incidents, she said, but she also tracks thwarted incidents, when an error could have happened but didn’t. The combined efforts have led to changes the faculty see working.

“When they see true changes in clinical care as a result of reporting and analysis, that also encourages more reporting,” Taylor said.

Cleland said part of the process is winning the medical staff’s trust.

“We had to show that we are here to help them and not serve as a watchdog,” he said.

He adds that ultimately, risk management serves to strengthen the health care delivery system.

“Patients appreciate it when you’re up front and they perceive you’re being honest,” he said. “That can only be a good thing and improves doctor-patient relationships.”

-Patrice Sawyer Guilfoyle

2009-09-02 00:00:00 18972