Patient Safety: Stamping Down on Medical Error

Healthcare 10 minute read

17 May 2021 10 minute read

Ibán Suárez Product Manager, Codimg

17

May, 2021

On the 3rd of May 2016, the British Medical Journal published an academic review titled Medical Error - the Third Leading Cause of Death in the US by Martin Makary and Michael Daniels of the Department of Surgery at John Hopkins University School of Medicine. In this study they asserted that, behind cancer and heart disease, medical error could be attributed to as many as 251,000 deaths in American hospitals while making suggestions for improved patient safety.

 

 

In the proceeding years, this review has turned into somewhat of a meme, with Makary’s and Daniels figures being quoted as gospel on social media and in all 4 corners of the internet. If true, it would mean that some 35% percent of in-hospital deaths in the US were caused by medical error and malpractice, a figure which has been widely debunked by various scientific sources since being published.

 

Nevertheless, despite the flaws in their methodology and extropolation, the original study by Makary and Daniels has good points to make - medical error DOES exist, of this there is no doubt, and there are things we can do to make it more visible and thus preventable.

 

In a post-COVID world, this becomes more important than ever.

 

Medical Error - The Third Biggest Cause of Death

 

Visibility = Reduction

As part of their strategies for improvement, Makary and Daniels suggest several changes including making errors more visible so their effects can be understood.

 

They say that more often than not, discussions about the prevention of errors occur behind closed doors in limited or confidential forums such as a department’s morbidity and mortality conference. They want to bring these discussions out into the open to shine a light on medical errors in order to effectively stamp them out. Their recommendations include changing death certificates to include not just the cause of death but also an extra field to say whether medical error contributed or not.

 

They developed this model for reducing patient harm from individual and systematic errors in hospitals and healthcare.

 

Model for Making Medical Errors More Visible

 

The authors also recommend that hospitals carry out a rapid and efficient independent investigation into preventable deaths in order to ascertain whether human error played a role. A root cause analysis approach would help while offering the protection of anonymity, they say.

 

 

Great Strides and the Importance of Teamwork

Since the publication of the article there has been some movement in improving on patient safety and cutting down preventable errors. Both the British and Spanish National Health Services have made great strides to improve their patient safety policies. Similarly, the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD) have developed a system called Team STEPPS 2.0. 

 

This system acknowledges that efficient teamwork has a large role to play in patient safety and insist that their model “offers a powerful solution to improving collaboration and communication with the healthcare institution”.

 

Team Stepps 2.0 - Improve Patient Safety

 

“Teamwork has been found to be one of the key initiatives within patient safety that can transform the culture within health care. Patient safety experts agree that communication and other teamwork skills are essential to the delivery of quality health care and to preventing and mitigating medical errors and patient injury and harm”.

 

 

The Importance of Effective Communication

 

teamwork in surgery

 

All of these organisations work on the basis that effective communication skills are vital for patient safety. The ability of a multidisciplinary team to interact successfully using both formal and informal feedback is key to providing essential feedback and improving team performance.

 

It is scientifically proven that direct observation is one of the principles of human learning. When we have a model to follow or formative feedback, we able to make changes and improvements in our behaviour. Step-by-step, we integrate what we see and learn into our own practice and, ultimately, improve our own performance which, in turn, improves patient safety.

 

In this context video analysis with software such as Codimg can be extremely useful.

 

 

Technology for Patient Safety

 

nursing reviewing practice

 

Video analysis has been used successfully for many years in the field of high-performance sports and we believe that this type of observation and analysis can be transplanted successfully into other fields, including healthcare and, specifically, the prevention of medical error and patient safety.

 

Codimg is an innovative tool which is easy to handle, gives maximum flexibility and provides those responsible for developing new skills, such as clinical educators and medical simulation providers, with added value. It allows for the sharing of good practice and reinforces the same, integrating teamwork and communication skills into clinical and hospital skills training. All of this is essential for achieving safer results.

 

The flexibility of Codimg allows people to analyse at their own pace, either in real-time or retrospectively, providing quantitative data of clinical processes which, in turn, gives the opportunity for self-control and self-regulation.

 

With Codimg you can:

 

•    Avoid human errors and situations of conflict.


•    Maximise profitability can eliminating the cost of face-to-face assessment.


•    Create a non-invasive method of evaluation of the intangible aspect of clinical assessment (creativity, emotions, etc.).


•    Provide objective proof of actions realised in the clinical environment. 

 

The innovative Codimg solution allows clinical educators and students to analyse their own performance or that of the team. It provides a personalised evaluation of progress and empowers practitioners by sharing examples of best practice, providing systematic feedback and providing a comparison of different medical techniques.

 

 

How Does Video Analysis Work

 

 

The clinical situation is filmed from various angles and the resultant video is observed and reviewed. During the observation, actions which are related to predesigned parameters are tagged. This allows us to build a database of video clips and data which can then be analysed, compared and organised. The analysis can then be shared while good and bad practice can be discussed and remedied. These corrections will then improve patient safety.

 

The Codimg solution is quick and effective and allows us to explore and understand human behaviour in a clinical setting. It means that we can see the learning process, decision making and emotions using technological solutions.

 

Video analysis can also be used for very specific clinical scenarios.

 

The Analysis of COVID-19

 

The proliferation of cases of the Corona Virus throughout the last year has, without doubt, been the biggest challenge to the medical profession in decades. COVID-19 has put everyone on the back foot and has changed the world in ways that we don’t yet realise.

 

Hospitals and healthcare centres all around the world have been pushed to their very limits trying to deal with a brand-new threat that few people really understood.

 

Due to this, we at Codimg wanted to do our bit to help out in this time of global crisis. As such, we spoke to a variety of healthcare professionals and came up with a solution which could help in the monitoring of airways of patients affected by the virus.

 

Codimg Covid Template

 

We realise that our contribution is but a drop in the ocean, but we are happy to provide this solution alongside a free temporary software license to any institution involved in the battle against Codimg. Contact us for more information.

 

We would also like to take this opportunity to applaud all the front-line workers putting their lives at risk on a daily basis in order to control the virus. Thank you!

 

 

Conclusion

Codimg offers a full analytical solution which can help stamp out medical error and improve patient safety. It is an intuitive adaptable solution to many of the challenges faced in the clinical environment and is a tool which is perfect for observing and sharing good practice in hospitals.

 

We can tailor Codimg to your needs, taking into account the size and scale of your operation. We can also provide you with actionable advice for the improvement of patient safety.

 

Contact us at sales@codimg.com or +34 622 203 784 +34 928 363 816 from Monday to Friday from 08.00 to 20.00 (UTC + 0) to get the ball rolling.

 

We look forward to hearing from you!

 

 

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