Tuesday, October 6, 2009

Safety Gurus: Penalize Doctors Who Don’t Follow the Rules

October 1, 2009, 3:50 PM ET
By Laura Landro

Should hospitals start penalizing doctors and nurses who fail to follow patient safety rules?

That’s one solution proposed by Peter Pronovost of Johns Hopkins and Robert Wachter of the University of California at San Francisco. Writing in the New England Journal of Medicine, the doctors contend that the failure to hold clinicians accountable for patient safety is the main reason health care is still riddled with errors, adverse events, and just plain non-adherence to some of the most basic rules.

(Compliance with hand hygiene rules ranges from 30% to 70% at most hospitals, and few have sustained rates over 80%, the authors note, while there are about 4,000 wrong-site surgeries in the U.S. annually despite a universally accepted protocol for preventing them.)

In the decade since the Institute of Medicine’s landmark “ To Err is Human” report, which estimated that up to 98,000 people a year die of medical errors, many hospitals have embraced a “no blame” model: Instead of focusing on a single individual to blame for a mistake, they’ve tried to set up systems to prevent mistakes, catch them before they cause harm, or mitigate harm from errors that do reach patients. That’s all well and good if it works, but many hospitals are now finding that a blame-free culture creates its own safety risks, Pronovost and Wachter write.

Punishments such as revoking privileges for a chunk of time tend to be used for administrative infractions that cost the hospital money – things like failing to sign the discharge summaries that insurance companies require to pay the hospital bill. By contrast, hospital administrators may just shrug their shoulders when it comes to doctors who fail or refuse to follow rules like a “time out” before surgery to avoid operating on the wrong body part.

Docs and nurses who fail to follow rules about hand hygiene or patient handoffs should lose their privileges for a week, Pronovost and Wachter suggest. They recommend loss of privileges for two weeks for surgeons who who fail to perform a “time-out” before surgery or don’t mark the surgical site to prevent wrong-site surgery.

Pronovost — best known for his development of medical checklists designed to improve patient safety — tells the Health Blog that he still sees a tremendous amount of “pushback” when he speaks to doctors. Many still resist checklists and don’t feel bound by hand washing rules, even though they’ve been shown to prevent harm to patients.

“Some of these doctors just come to the meetings to throw spears at me,” he says. “We know how important these things are for patient safety, but there needs to be some accountability for infractions,” he adds. The suggested penalties “are an attempt at a practical way to hold people accountable.”