Medical errors are the third-leading cause of death in the United States—right after heart disease and cancer and more prevalent than respiratory ailments, stroke and Alzheimer's disease—according to a study out this year from The BMJ (formerly the British Medical Journal). Author Martin Makary, MD, of Johns Hopkins University, and colleagues estimate that 251,000 Americans die each year from such mistakes.
The findings are far from the final word on the matter—they are based on statistical analyses of past studies and not on counts of actual errors, for example—but they underscore what has become an increasing public concern.
"While we have known for some time that medical errors are a source of morbidity and mortality, these recent studies show how unfortunately frequent they are," says APA President Susan H. McDaniel, PhD, whose career has focused on strengthening communication on integrated-care teams and between providers and patients.
The new research also supports psychologists' previous findings that medical errors often have psychological components to them—problems related to teamwork, communication, technology design, leadership and human decision-making—and that psychologists can help develop systems to prevent them. "Psychologist researchers, consultants and practitioners have an opportunity to make real contributions to this arena—describing the gaps that result in errors and how to create processes and communication that provide checks against inevitable human error," McDaniel says.
For understandable reasons, most people think that the experts in a given field—pilots in aviation, physicians in health care—are best equipped to understand how to make their systems better, adds University of Utah psychologist Frank Drews, PhD, who studies systems errors and design. But, he says, psychologists who specialize in human factors, industrial-organizational psychology and related areas "are actually better equipped to understand performance in these complex systems. It's really us in collaboration with medical specialists who can help to reduce problems like medical errors."
Evidence-based interventions
As any psychologist on an integrated-care team can tell you, good teamwork is essential to ensuring that patients are treated safely.
"Patient care is a team sport," says Eduardo Salas, PhD, who studies medical teamwork at Rice University. "It's not just your physician or your surgeon who makes a difference in the quality of a patient's care—it's providers, staff and administrators working together at all levels of the health-care system who foster the right patient outcomes."
If good teamwork does not exist, however, research shows that almost anything can go wrong—patients may receive the wrong dose or type of medication, get treated for the wrong condition or acquire a life-threatening infection from contaminated equipment, to name a few possibilities.
Salas has found that effective teamwork includes six key ingredients: cooperation, coordination, shared cognitions or views of the patient's situation, good communication protocols, mechanisms to resolve conflict and good leaders—coaches who facilitate, promote and encourage teamwork. Researchers have incorporated these and similar factors into a variety of training protocols, including the popular TeamSTEPPS, now used in about 70 percent of U.S. hospitals. Designed under the auspices of the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense by psychologist David Baker, PhD, a consultant in Washington, D.C., with input from Salas and others, it uses evidence-based tools that encourage good collaboration and communication to protect patient safety. Examples include call-outs, a "closed-loop" strategy where team members use a question-and-answer format to convey accurate information about critical aspects of patient care; and check-backs, a similar type of communication that ensures the receiver understands information in the way the sender intended it.
Overall, such team training programs have helped to reduce medical errors by about 20 percent, report Salas and colleagues in a meta-analysis in press at the Journal of Applied Psychology.
Another strategy outlined in TeamSTEPPS concerns creating good handoff protocols. Handoffs—when one set of providers passes a patient's care on to another set—are so ripe for error that the Accreditation Council for Graduate Medical Education has identified them as a national patient-safety improvement priority and now requires residency programs to provide formal instruction in doing them properly.
At least two large prospective studies have shown that training in handoff protocols leads to significant reductions in medical errors and poor patient outcomes (Journal of the American Medical Association, 2013, and New England Journal of Medicine, 2014).
Lending further support to those findings is a meta-analysis of 36 studies now under review. On the whole, evidence-based handoffs improve patient, organizational and provider outcomes, find human factors psychologists Joseph R. Keebler, PhD, Elizabeth H. Lazzara, PhD, of Embry-Riddle Aeronautical University, and colleagues. Good handoffs share several key properties, among them appointing one person to oversee the process; minimizing distractions; and modeling good handoff behavior, which includes talking with the next set of providers face-to-face and providing all necessary information in a clear way.
Other psychologists are looking at ways to tackle specific medical problems. One of these is surgical site infections, which afflict some 157,000 U.S. inpatients each year and are the most common type of hospital-acquired infection, according to the Centers for Disease Control and Prevention (CDC). Working as part of a multidisciplinary team, industrial-organizational psychologists Sallie Weaver, PhD, and Mike Rosen, PhD, of Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, are adapting a five-step team safety intervention developed for reducing infections in intensive-care settings to the surgical setting. The original protocol uses such strategies as identifying team leaders, educating teams on the science of safety, identifying and learning from problems, and using checklists and feedback to ensure that team members safely insert, remove and monitor central-line catheters. The differences between the two medical settings call for a unique protocol, Weaver explains. While the ICU is relatively contained and uses the same staff with each patient, the surgical process involves multiple providers in multiple settings, thus ramping up chances of mistakes. "It's an enormous system of care," she says.
Through webinars, a tool kit and coaching, the researchers are training five large cohorts of surgical teams from 197 U.S. hospitals in the five-part intervention—a total of about 397 specialty surgical teams in all, Weaver says.
A key element of the intervention is fostering involvement from the groups, which meet monthly to discuss what they've learned and address issues unique to their settings.
The team is still analyzing the data, but so far, the adaptation has lowered surgical infection rates by roughly a third across all sites taking part in the program, Weaver says.
Technology's risks and rewards
As important as person- and team-related problems in health-care safety are those associated with technology, including lack of training in electronic medical records and other technology, lack of standardized equipment, and poor equipment monitoring or oversight.
And such problems are likely to grow, predicts psychologist Vimla L. Patel, PhD, director and senior research scientist at the Center for Cognitive Studies in Medicine and Public Health at the New York Academy of Medicine.
"Technology has reduced a number of types of errors like medication errors," she says, "but at the same time, it has increased other kinds of errors, and the nature of errors has changed."
An example is a feature of some electronic medical records technology, which aids diagnosis by putting patient symptoms through a filtering support system. While that strategy may in many cases lead to quicker, more accurate diagnoses, it can also wipe out vital information that doesn't square with the program's algorithm, thus changing clinicians' reasoning patterns.
"We need to train medical students and other health-care trainees on how to use health technology safely in the clinical setting, including troubleshooting it and knowing when and how it can go wrong," Patel says.
In the meantime, other psychologists are tackling the problem by designing equipment that is easier to use.
Drews's team, for instance, has been developing graphic displays that give an overall sense of complex patient information. In general, the displays are akin to artificial horizons in an aircraft, where many types of real-time information appear on a single display so that people can more easily assess the big picture.
In an integrated cardiac display that Drews designed, for instance, information about a patient's cardiovascular system—blood pressure in the central veins and arteries, heart rate, oxygen levels and other measures—are conveyed in electronic graphics that mimic the look of a blood vessel. As blood pressure increases in a portion of the cardiovascular system, the "vessel" increases in diameter, giving a dual sense of a patient's blood pressure and blood volume, he explains.
In a 2013 paper in Human Factors, Drews and Alexa Doig, PhD, also of the University of Utah, found that when nurses were given a similar integrated display highlighting patients' vital signs—blood pressure, oxygen levels, and heart and respiration rates—they reacted more quickly and accurately than nurses using standard displays that show each element separately in a numerical format.
Drews also has designed kits to protect health-care workers and patients from viruses and infections. With a three-year grant from the CDC, he's designing a kit for providers working with patients infected with Ebola and other dangerous viruses. The kit helps providers and workers don and doff protective gear by organizing it in the proper sequence of use, thus reducing cognitive workload and promoting efficiency.
Promoting leaders' buy-in
Of course, even the best teams, technology and equipment won't ensure patient safety if the system doesn't support them. The greatest challenge in this realm is sustainability, says Salas. "How do you maintain this set of behavioral attitudes, skills and conditions over time?" he asks. "Training alone won't do it. That's about what leadership does."
In one effort to meet this challenge, Rosen and Weaver are using a three-year grant from the AHRQ to develop a computer-based training on safety and quality for medical executives, using a gamelike format they're developing with researchers at the Johns Hopkins Applied Physics Lab. For example, one scenario addresses the failed implementation of a new safety improvement intervention, and asks executives to troubleshoot why the implementation might have gone wrong.
The team hopes to take the training into the real world by setting up the technology so that people can replicate features of their own medical organizations and bring people together to solve problems.
"When you sit in meetings, it can be tough to share your perspective sometimes, tough to engage because other people are talking," says Rosen. "Here, you can do something a little more active and get better input from people."
