Medical mistakes can be life-altering for patients and their families. Fortunately, new technology can help reduce the risk of errors by identifying potential problems before they occur and alerting clinicians to them.
The UW Medical Center Clinical Error Advocate is a program that uses data analytics to identify high-risk patients and flag them to staff when they are admitted to the hospital. The data is gathered from a variety of sources, including the EHR and patient charts. The data is analyzed by a team of trained analysts to see patterns and predict potential issues.
If an analysis detects a potential problem, the information is sent to the care provider and a nurse. Depending on the severity of the issue, it can trigger additional screenings or even the initiation of an adverse event report. The program has been in place at the UWMC for about five years. In that time, the number of patient-perceived breakdowns has decreased by about 30%.
A new study finds that the most common breakdowns in health care involve miscommunication and misunderstanding of patient needs by medical providers and health care team members. The researchers, from the University of Washington School of Medicine and a consortium of nine other institutions, studied 183 incidents involving a breakdown in communication between health care teams.
The incidents occurred in a range of settings, including the operating room and emergency departments. The authors call for a more structured approach to communication among health care workers, such as the “closed loop” system pioneered in aviation, where instructions are repeated back to confirm they were understood. The system would also help with documentation of what transpired during a patient encounter, which is critical to the investigation of medical error and the creation of improved health care systems.
In the case of the COVID-19 breach, Dellit said the issue was a human error that led to the files becoming available online, and the organization is evaluating the possibility of a federal inquiry into its handling of the incident. King County Councilmember Reagan Dunn, who represents the affected area, has introduced legislation calling for a commission to investigate the incident, including the time it took for patients to be informed about the security breach.
UW Medicine has taken steps to avoid similar breaches in the future, including improving staff communication across its health system and instituting a system-wide review of policies and practices. The system also has a dedicated communications coordinator, who can help employees and family members navigate the process of reporting errors.
UW Medicine does not condone unprofessional behavior, and those who engage in such conduct may be subject to disciplinary action up to and including termination. Individuals should seek counsel from their supervisor or one of the many avenues for redress that are available depending on the circumstances.