The Institute of Medicine’s 1999 report, To Err is Human: Building a Safer Health System, stated that up to 98,000 Americans die each year in hospitals because of preventable mistakes — or as Michael Handler, M.D. ’84, put it, “the equivalent of a jumbo jet crash every one to two days.”
Handler, a hospital leader and expert in patient safety, gave the keynote address at the second annual Vijay Babu Rayudu Quality & Patient Safety Day program at the UMKC School of Medicine on May 15.
An obstetrician-gynecologist by training, Handler is the medical director and chief medical officer of SSM St. Joseph Hospital West in Lake Saint Louis, Missouri. He is also the medical director of the Center for Patient Safety, a not-for-profit organization established by the Missouri Hospital Association, the Missouri State Medical Association and the health-care consulting firm Primaris.
“As I think about patient safety, I think about three expectations the patient has,” said Handler, who sees the Institute of Medicine report as the genesis of the patient safety movement. “The patient has expectations of ‘don’t hurt me, be nice to me and cure me,’ and probably in that order.”
According to Handler, it is imperative for health-care organizations to develop a culture of safety, which acknowledges the high-risk nature of the work, avoids blame and promotes collaboration across disciplines. Strong leadership is also necessary, he said.
“One thing I want to remind you is, all physicians are leaders,” Handler said. “It doesn’t matter if you have a title or if you’re a director or if you’re a chairperson or whatever. Every single physician is a leader. Everybody is looking at you. It’s like you’re onstage all the time. You always have to pay attention to that in everything that you do.”
Handler believes health-care organizations have changed their approach to patient safety. The focus used to be on the individual. Today, organizations focus on systems, such as the way doctors and nurses transfer patient responsibility during shift changes. “The way to reduce errors is to learn about the causes of errors and use this knowledge to redesign the systems,” he said.
Handler also stressed that working toward a blame-free culture is not a shirking of accountability. He drew a distinction between mistakes that should be met with coaching and more rare instances of “willful neglect.” A blame-free culture encourages health workers to document unsafe conditions and near misses, which are great learning opportunities, said Handler.
“You want people to report. You want the culture to be such that people are not afraid of retribution.”
With an eye on the horizon, Handler said diagnostic errors will become an area of focus in coming years. In fact, an Institute of Medicine committee is evaluating the existing knowledge about diagnostic error and its role in the quality of care, he said.
Peter Almenoff, M.D., the Vijay Babu Rayudu Endowed Chair of Patient Safety, introduced Handler and welcomed the members of Rayudu’s family who were in attendance. Rayudu was a medical student at UMKC at the time of his death in 2007.
Following Handler’s talk, students made oral presentations on antibiotic utilization, the role of interpreters in emergency rooms and other topics. Residents and fellows presented posters in the School of Medicine lobby. A list of presenters is available at https://med.umkc.edu/docs/events/RayuduPatientSafety2015.pdf.