Guest Commentary: Improving Patient Safety - Challenges Ahead



Patrick Monaghan
Director of Communications
Jefferson School of Population Health

Sitting in Connelly Auditorium on Monday morning, surrounded by Jefferson Medical College’s (JMC) third year students, I sipped my coffee and put myself in their shoes.

I’m glad I was only trying them on for size.

At the 8th Annual Interclerkship Day on Improving Patient Safety, I felt the weight of the career path these young men and women had chosen and the enormous import of improving our nation’s horrifying record of patient safety. Despite improvements made since the 1999 release of the Institute of Medicine (IOM) report To Err is Human, the statistics remain startling: One in five Americans (22%) report that they or a family member have experienced a medical error of some kind. According to the Centers for Disease Control, in American hospitals alone, hospital-acquired infections account for an estimated 1.7 million infections and 99,000 associated deaths each year.

In the more than 10 years since the IOM report was released, it would be difficult to measure any real progress, noted Kenneth J. Abrams, MD, MBA, one of the day’s speakers. Dr. Abrams, Sr. Vice President of Clinical Operations, Chief Quality Officer and Associate Chief Medical Officer at The North Shore-LIJ Health System, is responsible for clinical operations, quality, and patient safety initiatives across North Shore-LIJ’s facilities in the New York area.

Dr. Abrams explained how LIJ uses simulation training to improve quality and safety. These training scenarios replicate situations in multiple medical environments, including a critical care unit, emergency department or operating room. Twice a year, residency teams do battle in Sim-Wars, a patient simulation competition that reinforces the importance of teamwork in positive clinical outcomes.

“Team performance will always exceed that of the individual,” Dr. Abrams said. “We need to educate nurses and physicians together in teams.”

A point well taken, I’m sure, by the day’s keynote speaker – internationally known aviation safety expert, John J. Nance, JD. Nance is a founding board member of the National Patient Safety Foundation; a former airline pilot, and a broadcast analyst on aviation for ABC News.

Nance is a compelling speaker, and I can only hope that he reached these future physicians as he had me. My key takeaway? We are human and we make mistakes.

Which goes against the premise that for at least the last century American medical schools, almost without exception, have labored to prepare their students to be superhuman – practitioners who, once done with internship and residency, can practice medicine without making serious mistakes and without the need of anyone else’s assistance, advice, or counsel on medical matters.

Physicians attempting to be autonomous, said Nance, account for a staggering number of inadvertent patient injuries. Many times injuries are not the result of a physician refusing to listen, but intimidated staff refusing to speak up and assuming that the physician is infallible.

As a Jefferson employee, I know the University continues to develop curricula that foster a team approach to treatment. Innovative instruction unfolds here daily through the Jefferson InterProfessional Education Center, while our own Clinical Skills and Simulation Center uses state-of-the-art technology to create realistic medical training simulations for students.

Sponsored by the Office of the Dean of JMC and the Jefferson School of Population Health (JSPH), the program was moderated by David B. Nash, MD, MBA, the Dean of JSPH. The day featured equally compelling presentations by Jefferson’s Geno Merli, MD, FACP; Valerie D. Weber, MD, Chair, Clinical Sciences, The Commonwealth Medical College; and Jefferson’s Jason Baxter, MD, MSCP, who was making his eighth consecutive appearance at Interclerkship Day.

I walked away with a better understanding of the challenges that lie ahead for these third year students. Hopefully they felt a little more prepared to meet them.

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