You might be familiar with the case where the actor Dennis Quaid's twins were harmed by an overdose at the famed Cedar-Sinai Hospital in Los Angeles. I blogged about it originally in late 2007 as the post “How Often Must the Same Mistake Be Repeated?” The post title referenced the fact that the exact same set of circumstances led to the death of three babies in Indianapolis in 2006 (see “Lack of Error Proofing Kills 3 Babies”). Here is a complete list of my blog posts mentioning the Quaids.
Thankfully, Quaid's twins survived. Dennis and his wife Kimberly have been using their celebrity status to try to bring positive change around patient safety – particularly with a systems focus. Dennis is getting out there again as the “frontman” for a new push to raise awareness about systemic medical errors, including an upcoming Discovery Channel documentary called “Chasing Zero: Winning the War on Healthcare Harm.” More about the show, including video clips, here.
From this article about the upcoming show:
The made-for-TV documentary, “Chasing Zero: Winning the War on Healthcare Harm,” will be the first in a series of stories from consumers, front-line caregivers, clinical and non-clinical leaders of hospitals, and international subject matter experts of their experiences with medical error. Quaid says the documentary It will highlight the simple things that patients and caregivers can do to reduce medical error. He hopes that these stories will raise awareness of how preventable medical error is.
You can see some video of Quaid speaking at the National Press Club, via C-SPAN (skip to about 5:30 into the video to skip some of the introductions of different people there… he speaks until about 24 minutes in, then Q&A from the audience).
Quaid emphasizes that we have the ability to reduce preventable errors to almost zero. He says that part is more shocking than the fact that healthcare harm is the third leading cause of death in the United States.
Quaid is looking not just to prevent errors, but to support healthcare workers.
“I have learned that the overwhelming majority of health care harm is due to the failure of the systems that support (health care workers),” Quaid said. “We don't have bad people. We have bad systems. The good news is we can fix them.”
I think this is an important point. People working in healthcare don't want to make mistakes or be involved in errors that harm patients. Quaid says he isn't here to denigrate doctors, nurses, pharmacists, etc. He realizes they are very caring and they're often overworked. They're often “working without a safety net.” It's the systems, not the people. This is a common Lean theme, as well.
Quaid refers to the need for quality improvement as “real healthcare reform,” a phrase we've used often in our discussions about lean healthcare within the Lean Enterprise Institute and the Healthcare Value Leaders Network. Regardless of what happens in DC, we still need lean and other methods for quality and patient safety.
Here is a USA Today story about Quaid and his awareness raising efforts. The story gives some detail about the impact of the error that almost killed the twins:
That megadose of heparin practically turned their blood to water, Quaid said, and they began bleeding externally and internally. At one point, he says, blood from his son's umbilical cord squirted 6 feet and hit a wall. Finally, after 41 hours, the twins' blood was again clotting normally, and they made a full recovery, for which Quaid credits “a lot of praying by a lot of people.”
I'm thankful that Dennis Quaid is working, through his Quaid Foundation, to help raise awareness about:
- How widespread the problem of medical harm is
- How preventable it can be through leadership, safe practices (including “standardized methods” like checklists), technology, and the right organizational culture to support these systems
While he focuses a lot on technology, I'm very glad that Quaid also emphasizes leadership, systems, and culture. Technology alone won't be enough.
The National Quality Foundation, working with Quaid, has released a new report about how to prevent errors and Hospital Acquired Infections (“Safe Practices for Better Healthcare“). You can download their mini-report for free (PDF). Some of the stats from the NQF site:
Medical errors cause significant harm to patients in healthcare settings across the country.
- In 2008, the Agency for Health Care Research and Quality (AHRQ) reported that preventable medical injuries are actually on the riseâ€”by one percent a year.
- Healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year.
- At least 1.5 million preventable drug events occur each year due to drug mix-ups and unintentional overdoses.
- Eighteen types of medical errors account for 2.4 million extra hospital days and $9.3 billion in excess charges each year.
The harm can also be measured in heavy financial cost. Preventable errors have been estimated to cost the United States $17 – $29 billion per year in healthcare expenses, lost worker productivity, lost income and disability. Meanwhile, healthcare expenditures are growing at more than seven percent per year and patient safety is improving by only one percent.
The good news is that with Safe Practices healthcare systems have a key to truly drive improvement in quality and patient safety.
Important stuff to keep in mind. That's why this patient safety fight is so important. And Lean is part of the answer.
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